Provider Demographics
NPI:1841505567
Name:JACKSON, ANGELA ALLEN (NP-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE STREET
Mailing Address - Street 2:UMMC-DEPARTMENT OF DERMATOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-3374
Mailing Address - Fax:601-815-0983
Practice Address - Street 1:1010 LAKELAND PL
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6678
Practice Address - Country:US
Practice Address - Phone:601-815-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873582363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05728527Medicaid
MS302I506602Medicare PIN
MS05728527Medicaid