Provider Demographics
NPI:1265170179
Name:DOMINGUE, JENNIFER (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOMINGUE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 NE 138TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-3823
Mailing Address - Country:US
Mailing Address - Phone:305-494-9999
Mailing Address - Fax:
Practice Address - Street 1:1051 NE 138TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-3823
Practice Address - Country:US
Practice Address - Phone:305-494-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019511363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty