Domonique Jackson, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Practice address

752 Blanding Blvd Ste 130
Orange Park, FL 32065-5790

Phone

(904) 637-5297

NPI assigned

Feb 2, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 1, 2023 through Oct 1, 2027

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1485993600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1593043200000",
    "number": "1063950731",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3045 RUSSELL RD",
            "city": "GREEN COVE SPRINGS",
            "state": "FL",
            "postal_code": "320438209",
            "telephone_number": "904-505-1844"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "752 BLANDING BLVD STE 130",
            "city": "ORANGE PARK",
            "state": "FL",
            "postal_code": "320655790",
            "telephone_number": "904-637-5297"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3100 University Blvd S Ste 218",
            "address_purpose": "LOCATION",
            "city": "Jacksonville",
            "state": "FL",
            "postal_code": "322162727",
            "country_code": "US",
            "telephone_number": "904-535-1844",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "DOMONIQUE",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-02-02",
        "last_updated": "2020-06-25",
        "certification_date": "2020-06-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in Orange Park, FL
• Providers in Orange Park, FL by specialty
• Clinical Social Worker in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.