Provider Demographics
NPI:1952695652
Name:JACKSON, ANGELA MICHELLE (MCP, BHRS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MCP, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 HUNTERS HILL DR
Mailing Address - Street 2:APT. 721
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2311
Mailing Address - Country:US
Mailing Address - Phone:580-231-1659
Mailing Address - Fax:
Practice Address - Street 1:2501 HUNTERS HILL DR
Practice Address - Street 2:APT. 721
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2311
Practice Address - Country:US
Practice Address - Phone:580-231-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor