Provider Demographics
NPI:1871048280
Name:DOMINGUEZ, JESUS MONSERATT (PT)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:MONSERATT
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:STE 240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5745
Mailing Address - Country:US
Mailing Address - Phone:941-955-1108
Mailing Address - Fax:941-954-4440
Practice Address - Street 1:943 S BENEVA RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2476
Practice Address - Country:US
Practice Address - Phone:941-955-1850
Practice Address - Fax:941-955-1852
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019384225100000X
FLPT31006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist