Healthcare Provider Details

I. General information

NPI: 1891382339
Provider Name (Legal Business Name): DOMINIQUE JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE JACKSON PITTMAN

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 MORTHLAND DR UNIT 1086
VALPARAISO IN
46383-5914
US

IV. Provider business mailing address

3009 WINTER GARDEN DR
VALPARAISO IN
46385-7140
US

V. Phone/Fax

Practice location:
  • Phone: 219-508-5646
  • Fax:
Mailing address:
  • Phone: 219-613-7872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34009080A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009080A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.028567
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: