Provider Demographics
NPI:1508597725
Name:JACKSON, DYNASTY (NBHWC, LBSW)
Entity Type:Individual
Prefix:MRS
First Name:DYNASTY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NBHWC, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 12TH ST N
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35203-1537
Mailing Address - Country:US
Mailing Address - Phone:855-255-2362
Mailing Address - Fax:
Practice Address - Street 1:110 12TH ST N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35203-1537
Practice Address - Country:US
Practice Address - Phone:855-255-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3167787171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach