Provider Demographics
NPI:1023513363
Name:JACKSON, ANGENIQUE GLORIANN (DC)
Entity type:Individual
Prefix:DR
First Name:ANGENIQUE
Middle Name:GLORIANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ANGENIQUE
Other - Middle Name:GLORIANN
Other - Last Name:DEJESUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:316 INLAND COVE CT
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1171 MARKET ST STE 112
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6502
Practice Address - Country:US
Practice Address - Phone:803-802-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor