Provider Demographics
NPI:1245106228
Name:JACKSON, ANGEL HEART (LMSW)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:HEART
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4500
Mailing Address - Country:US
Mailing Address - Phone:337-269-5000
Mailing Address - Fax:337-269-5001
Practice Address - Street 1:111 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4500
Practice Address - Country:US
Practice Address - Phone:337-269-5000
Practice Address - Fax:337-269-5001
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17884104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty