Provider Demographics
NPI:1417177320
Name:JACKSON, ANGELINA R (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DAWSON ST
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-6402
Mailing Address - Country:US
Mailing Address - Phone:956-287-7912
Mailing Address - Fax:
Practice Address - Street 1:7017 N 10TH ST
Practice Address - Street 2:STE T
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3287
Practice Address - Country:US
Practice Address - Phone:956-630-6300
Practice Address - Fax:956-630-3443
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12799851224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant