Provider Demographics
NPI:1144599366
Name:JACKSON, ANGELIQUE MECHELLE (RN, APN-BC)
Entity Type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:MECHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 MAPLE TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5453
Mailing Address - Country:US
Mailing Address - Phone:678-754-7728
Mailing Address - Fax:
Practice Address - Street 1:1410 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4901
Practice Address - Country:US
Practice Address - Phone:678-754-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily