Provider Demographics
NPI:1417634916
Name:JACKSON-COY, DOMINIQUE (LSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:JACKSON-COY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8155 E FAIRMOUNT DR UNIT 2022
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6838
Mailing Address - Country:US
Mailing Address - Phone:719-432-6322
Mailing Address - Fax:
Practice Address - Street 1:7340 E CALEY AVE STE 220
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-6709
Practice Address - Country:US
Practice Address - Phone:719-432-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.00099242741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical