Provider Demographics
NPI:1104431790
Name:JACKSON, ANGELA P
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:P
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 1:5528 MEADOW PASSAGE DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8397
Mailing Address - Country:US
Mailing Address - Phone:614-886-7004
Mailing Address - Fax:
Practice Address - Street 1:5528 MEADOW PASSAGE DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-8397
Practice Address - Country:US
Practice Address - Phone:614-886-7004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant