Provider Demographics
NPI:1316446453
Name:JACKSON, ANGELA EVONNE (LMT/MMP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:EVONNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT/MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12336 SHADY SPRING WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9172
Mailing Address - Country:US
Mailing Address - Phone:407-427-6548
Mailing Address - Fax:
Practice Address - Street 1:12336 SHADY SPRING WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9172
Practice Address - Country:US
Practice Address - Phone:407-427-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA88337225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist