Provider Demographics
NPI:1639975725
Name:JACKSON, DOMINIQUE RENA (BS)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:RENA
Last Name:JACKSON
Suffix:
Gender:
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 61ST STREET, ST 301, 3RD FL,
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204
Mailing Address - Country:US
Mailing Address - Phone:402-252-8181
Mailing Address - Fax:402-252-8787
Practice Address - Street 1:2560 1ST AVE S APT 108
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1756
Practice Address - Country:US
Practice Address - Phone:402-317-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician