1639975725 NPI number — DOMINIQUE RENA JACKSON BS

Table of content: DOMINIQUE RENA JACKSON BS (NPI 1639975725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639975725 NPI number — DOMINIQUE RENA JACKSON BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
DOMINIQUE
Provider Middle Name:
RENA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639975725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1649 61ST STREET, ST 301, 3RD FL,
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-252-8181
Provider Business Mailing Address Fax Number:
402-252-8787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2560 1ST AVE S APT 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTOONA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50009-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-317-9235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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