Individual
DOMENICA RAEGENE NYCOLE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
12260 HIGHWAY 43, RUSSELLVILLE, AL 35653-4737
(256) 710-8558
Mailing address
238 LEWIS ST, MUSCLE SHOALS, AL 35661-1630
(256) 710-8558
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
6371G
AL
Other
Enumeration date
10/23/2023
Last updated
03/03/2024
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