Healthcare Provider Details

I. General information

NPI: 1770950305
Provider Name (Legal Business Name): ANGELICA JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELICA RAMIREZ

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 CLEAR LK CTY BLVD STE 102
HOUSTON TX
77062-8069
US

IV. Provider business mailing address

4706 SABERO LN
LEAGUE CITY TX
77573-4893
US

V. Phone/Fax

Practice location:
  • Phone: 713-493-1346
  • Fax:
Mailing address:
  • Phone: 951-970-7201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA11392
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-05899
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: