Healthcare Provider Details

I. General information

NPI: 1659619328
Provider Name (Legal Business Name): ANGELA WENDY JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8299 CAMBRIDGE ST 1602
HOUSTON TX
77054-3170
US

IV. Provider business mailing address

8299 CAMBRIDGE 1602
HOUSTON TX
77054
US

V. Phone/Fax

Practice location:
  • Phone: 713-826-8476
  • Fax:
Mailing address:
  • Phone: 713-826-8476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number522012
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: