MEDICARE: DOMINIQUE JACKSON PMHNP

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	163W00000X	Registered Nurse	767792	NY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	406069	NY

General Provider Information

NPI Number	:	1811696560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE JACKSON PMHNP

Provider Business Mailing Address
First Line	:	2244 BRONX PARK E APT 2D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-7516
Country	:	US
Telephone Number	:	407-924-3771
Fax Number	:

Provider Business Practice Location Address
First Line	:	148 POST AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-2667
Country	:	US
Telephone Number	:	845-267-1400
Fax Number	:

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

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	10/31/2024

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