Provider Demographics
NPI:1073923975
Name:JACKSON, ANGELA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:360-379-8031
Mailing Address - Fax:360-379-4383
Practice Address - Street 1:915 SHERIDAN ST.
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368
Practice Address - Country:US
Practice Address - Phone:360-379-8031
Practice Address - Fax:360-379-4383
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60638952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant