Healthcare Provider Details

I. General information

NPI: 1629992524
Provider Name (Legal Business Name): ALEXIA DOMINIQUE JACKSON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 KALAMAZOO ST
EAST LANSING MI
48824-5400
US

IV. Provider business mailing address

3127 TRAPPERS COVE TRL APT 2C
LANSING MI
48910-8478
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-9710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601003099
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: