Provider Demographics
NPI:1487373130
Name:JACKSON, CASIEL DOMINIQUE (LAC)
Entity type:Individual
Prefix:
First Name:CASIEL
Middle Name:DOMINIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45464 W LONG WAY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-7074
Mailing Address - Country:US
Mailing Address - Phone:248-934-9060
Mailing Address - Fax:
Practice Address - Street 1:1705 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6920
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-7258T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health