MEDICARE: DOMINIQUE JACKSON

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699544783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE JACKSON

Provider Business Mailing Address
First Line	:	5330 RUTLAND CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4785
Country	:	US
Telephone Number	:	404-913-6337
Fax Number	:	404-393-7473

Provider Business Practice Location Address
First Line	:	5330 RUTLAND CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4785
Country	:	US
Telephone Number	:	404-913-6337
Fax Number	:	404-393-7473

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2023
Last Update Date	:	12/29/2023

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