Provider Demographics
NPI:1124292826
Name:JACKSON, ANGELA PATRICE (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:PATRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:808 COMMERCE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-7192
Mailing Address - Country:US
Mailing Address - Phone:770-996-9191
Mailing Address - Fax:770-996-5298
Practice Address - Street 1:808 COMMERCE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-7192
Practice Address - Country:US
Practice Address - Phone:770-996-9191
Practice Address - Fax:770-996-5298
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA001627208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics