MEDICARE: ANGELA VERA JACKSON N.P.- C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95003924	CA

General Provider Information

NPI Number	:	1093262784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA VERA JACKSON N.P.- C

Provider Business Mailing Address
First Line	:	PO BOX 487
Second Line	:
City	:	SPRINGVILLE
State	:	CA
Zip	:	93265-0487
Country	:	US
Telephone Number	:	559-786-9730
Fax Number	:

Provider Business Practice Location Address
First Line	:	394 PEARSON DR
Second Line	:
City	:	PORTERVILLE
State	:	CA
Zip	:	93257-3368
Country	:	US
Telephone Number	:	559-783-8383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	09/09/2016

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