Provider Demographics
NPI:1831697382
Name:DOMINICK, JENNIFER (MPA, BSL)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:MPA, BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-2040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:PA
Practice Address - Zip Code:18643-1918
Practice Address - Country:US
Practice Address - Phone:570-655-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001760103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst