Healthcare Provider Details

I. General information

NPI: 1487487864
Provider Name (Legal Business Name): DOMINIQUE ALEXIS JACKSON PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W STE P-1
CLINTON MS
39056-4108
US

IV. Provider business mailing address

604 HIGHWAY 80 W STE P-1
CLINTON MS
39056-4108
US

V. Phone/Fax

Practice location:
  • Phone: 601-589-4854
  • Fax: 601-893-7096
Mailing address:
  • Phone: 601-589-4854
  • Fax: 601-893-7096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906979
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: