Healthcare Provider Details

I. General information

NPI: 1609691096
Provider Name (Legal Business Name): ANGEL JACKSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 BRYAN ST STE 5
HUNTINGDON PA
16652-2413
US

IV. Provider business mailing address

900 BRYAN ST STE 5
HUNTINGDON PA
16652-2413
US

V. Phone/Fax

Practice location:
  • Phone: 814-643-6300
  • Fax: 814-643-8776
Mailing address:
  • Phone: 814-643-6300
  • Fax: 814-643-8776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: