Provider Demographics
NPI:1679396790
Name:DOMINGUEZ, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 JOHNNY TELLES
Mailing Address - Street 2:
Mailing Address - City:CLINT
Mailing Address - State:TX
Mailing Address - Zip Code:79836
Mailing Address - Country:US
Mailing Address - Phone:915-328-8491
Mailing Address - Fax:
Practice Address - Street 1:8500 BOEING DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1224
Practice Address - Country:US
Practice Address - Phone:915-599-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109598104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker