Provider Demographics
NPI:1407560402
Name:JACKSON, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 MUDFORK ROAD
Mailing Address - Street 2:
Mailing Address - City:VERDUNVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25649
Mailing Address - Country:US
Mailing Address - Phone:304-784-0989
Mailing Address - Fax:
Practice Address - Street 1:298 TRICORN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053-7148
Practice Address - Country:US
Practice Address - Phone:304-369-1385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV91990163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse