Provider Demographics
NPI:1891382339
Name:JACKSON PITTMAN, DOMINIQUE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:JACKSON PITTMAN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3009 WINTER GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-7140
Mailing Address - Country:US
Mailing Address - Phone:219-613-7872
Mailing Address - Fax:
Practice Address - Street 1:3009 WINTER GARDEN DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-7140
Practice Address - Country:US
Practice Address - Phone:219-613-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009080A104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1891382339OtherNPI
IN300049653Medicaid