Healthcare Provider Details

I. General information

NPI: 1669077863
Provider Name (Legal Business Name): ANGELA JACKSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 511
DENVER CO
80201-0511
US

IV. Provider business mailing address

PO BOX 511
DENVER CO
80201-0511
US

V. Phone/Fax

Practice location:
  • Phone: 919-903-3838
  • Fax:
Mailing address:
  • Phone: 919-903-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701013995
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number804
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number86639
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14797
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: