Healthcare Provider Details

I. General information

NPI: 1407560402
Provider Name (Legal Business Name): ANGEL JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S RUFFNER RD STE 11
CHARLESTON WV
25314-1542
US

IV. Provider business mailing address

2866 MUDFORK ROAD
VERDUNVILLE WV
25649
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-9595
  • Fax:
Mailing address:
  • Phone: 304-784-0989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number123472
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91990
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: