Individual
MR. DOMINIQUE JEAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
19544 WOODHULL AVE, HOLLIS, NY 11423-2982
(646) 528-0327
Mailing address
13744 LAURELTON PKWY, JAMAICA, NY 11422-1708
(646) 528-0327
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
001894-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001894-1
PTA LISCENSE NUMBER
NY
05
—
83-2884615
—
NY
Enumeration date
02/21/2019
Last updated
02/21/2019
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