Healthcare Provider Details

I. General information

NPI: 1003756354
Provider Name (Legal Business Name): DOMINIQUE JACKSON MSW, RCSWI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 JAMES HINSON DR
MIDWAY FL
32343-2264
US

IV. Provider business mailing address

71 JAMES HINSON DR
MIDWAY FL
32343-2264
US

V. Phone/Fax

Practice location:
  • Phone: 850-405-5068
  • Fax:
Mailing address:
  • Phone: 850-405-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberISW22976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: