Provider Demographics
NPI:1851676134
Name:ANGELO, JENNIFER LEE (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:ANGELO
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:HEARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3211 N 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5145
Mailing Address - Country:US
Mailing Address - Phone:903-297-6500
Mailing Address - Fax:903-297-6510
Practice Address - Street 1:3211 N 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5145
Practice Address - Country:US
Practice Address - Phone:903-297-6500
Practice Address - Fax:903-297-6510
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651630363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX293397001Medicaid
TXTXB146575Medicare UPIN