Provider Demographics
NPI:1922870179
Name:JACKSON, DOMENICA RAEGENE NYCOLE
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:RAEGENE NYCOLE
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 1:238 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-1630
Mailing Address - Country:US
Mailing Address - Phone:256-710-8558
Mailing Address - Fax:
Practice Address - Street 1:12260 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-4737
Practice Address - Country:US
Practice Address - Phone:256-710-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6371G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker