MEDICARE: JACKSON MENTAL HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1144196940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MENTAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	1035 COURTNEY RD
Second Line	:
City	:	HERMANVILLE
State	:	MS
Zip	:	39086-7700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1035 COURTNEY RD
Second Line	:
City	:	HERMANVILLE
State	:	MS
Zip	:	39086-7700
Country	:	US
Telephone Number	:	601-448-9924
Fax Number	:	601-202-4010

Authorized Official
Title or Position	:	OWNER
Name	:	DOMINIQUE JACKSON
Credential	:	PMHNP-C
Telephone Number	:	601-589-4854

Provider Enumeration Date	:	10/17/2025
Last Update Date	:	04/29/2026

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