| Doctor Name: | JESSICA DOMST |
| NPI Number: | 1215327416 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA |
| License Number: | |
| Business Practice Address: | 393 North St Springville, NY - 141419652 |
| Business Phone Number: | 7165929331 |
| Business Fax Number: | 7165924683 |
| Mailing Address: | 393 North St, SPRINGVILLE |
| State: | NY |
| Postal Code: | 141419652 |
| Phone Number: | 7165929331 |
| Fax Number: | 7165924683 |
| NPI Enumeration Date: | 01/27/2015 |
| NPI Last Update Date: | 01/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041S0200X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |