Provider Demographics
NPI:1427341486
Name:JACKSON, ANGELA Y (RN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:Y
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PUTNAM AVE
Mailing Address - Street 2:APT# 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-6604
Mailing Address - Country:US
Mailing Address - Phone:718-399-3277
Mailing Address - Fax:
Practice Address - Street 1:415 PUTNAM AVE
Practice Address - Street 2:APT# 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-6604
Practice Address - Country:US
Practice Address - Phone:718-399-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY534684163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse