Provider Demographics
NPI:1679000814
Name:JACKSON, DOMINIQUE MECHELLE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MECHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766B LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4610
Mailing Address - Country:US
Mailing Address - Phone:601-982-2916
Mailing Address - Fax:601-366-2916
Practice Address - Street 1:766B LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4610
Practice Address - Country:US
Practice Address - Phone:601-982-2916
Practice Address - Fax:601-366-2916
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901975363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner