Provider Demographics
NPI:1659619328
Name:JACKSON, ANGELA WENDY (RN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:WENDY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8299 CAMBRIDGE
Mailing Address - Street 2:1602
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054
Mailing Address - Country:US
Mailing Address - Phone:713-826-8476
Mailing Address - Fax:
Practice Address - Street 1:8299 CAMBRIDGE ST
Practice Address - Street 2:1602
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-3170
Practice Address - Country:US
Practice Address - Phone:713-826-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX522012163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management