Provider Demographics
NPI:1982122628
Name:DOMINGUEZ, JACOB MAURO (LPN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MAURO
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4106
Mailing Address - Country:US
Mailing Address - Phone:718-541-5218
Mailing Address - Fax:
Practice Address - Street 1:223 BROOK AV
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454
Practice Address - Country:US
Practice Address - Phone:718-541-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329762164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse