Provider Demographics
NPI:1831918895
Name:JACKSON, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
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 1:20 S 3RD ST STE 210
Mailing Address - Street 2:PMB 1971281
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 S 3RD ST STE 210
Practice Address - Street 2:PMB 1971281
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4206
Practice Address - Country:US
Practice Address - Phone:614-815-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No253Z00000XAgenciesIn Home Supportive Care