Provider Demographics
NPI:1639263486
Name:JACKSON, ANGELA VICTORIA (RN, MSN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:VICTORIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHIEF EDDIE HOFFMAN HWY
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-543-6000
Mailing Address - Fax:
Practice Address - Street 1:5201 CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-3320
Practice Address - Country:US
Practice Address - Phone:615-222-1900
Practice Address - Fax:615-222-1917
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000008302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4301404OtherBCBST
TN3349491Medicaid
TNP01037353OtherRR MEDICARE
TN4321158OtherBLUE CROSS-BLUE SHIELD
TN4321158OtherBLUE CROSS-BLUE SHIELD
TN3349491Medicaid
TNP94002Medicare UPIN
TN103I081171Medicare PIN