Provider Demographics
NPI:1487487864
Name:JACKSON, DOMINIQUE ALEXIS (PMHNP-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ALEXIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 COURTNEY RD
Mailing Address - Street 2:
Mailing Address - City:HERMANVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39086-7700
Mailing Address - Country:US
Mailing Address - Phone:601-617-9659
Mailing Address - Fax:
Practice Address - Street 1:1035 COURTNEY RD
Practice Address - Street 2:
Practice Address - City:HERMANVILLE
Practice Address - State:MS
Practice Address - Zip Code:39086-7700
Practice Address - Country:US
Practice Address - Phone:601-617-9659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906979363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health