Healthcare Provider Details

I. General information

NPI: 1821492265
Provider Name (Legal Business Name): ANGELA JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 CENTENNIAL PL
TALLAHASSEE FL
32308
US

IV. Provider business mailing address

2606 CENTENNIAL PL
TALLAHASSEE FL
32308-0572
US

V. Phone/Fax

Practice location:
  • Phone: 850-205-0189
  • Fax: 850-329-2903
Mailing address:
  • Phone: 850-205-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9316685
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: