Provider Demographics
NPI:1013468248
Name:JACKSON, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
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 1:110 E ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04967
Mailing Address - Country:US
Mailing Address - Phone:207-355-4026
Mailing Address - Fax:
Practice Address - Street 1:110 E ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:ME
Practice Address - Zip Code:04967-5106
Practice Address - Country:US
Practice Address - Phone:207-355-4026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1666300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist