Provider Information for 1669042164
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DOMINIQUE JACKSON LCSW
Sex: Female
NPI: 1669042164
Last Updated: 2021-06-28
Certification Date: 2021-06-28
Certification Date: 2021-06-28
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1669042164 | ||||||||
| Enumeration Date | 2021-06-28 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 43847 RUSHCLIFFE DR STERLING HEIGHTS, MI 48313-1197 United States Phone: 586-610-5990 | Fax: | ||||||||
| Primary Practice Address | 43847 RUSHCLIFFE DR STERLING HEIGHTS, MI 48313-1197 United States Phone: 586-610-5990 | Fax: | ||||||||
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