Provider Demographics
NPI:1093394694
Name:JACKSON, ANGELA ANN (LCSW-S)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 GOLDENROD ST
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5459
Mailing Address - Country:US
Mailing Address - Phone:512-262-8126
Mailing Address - Fax:
Practice Address - Street 1:915 GOLDENROD ST
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5459
Practice Address - Country:US
Practice Address - Phone:512-262-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX617211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical