MEDICARE: ANGEL JACKSON

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	163W00000X	Registered Nurse	91990	WV
2	363LP2300X	Primary Care Nurse Practitioner	123472	WV

General Provider Information

NPI Number	:	1407560402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL JACKSON

Provider Business Mailing Address
First Line	:	2866 MUDFORK ROAD
Second Line	:
City	:	VERDUNVILLE
State	:	WV
Zip	:	25649
Country	:	US
Telephone Number	:	304-784-0989
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 S RUFFNER RD STE 11
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-1542
Country	:	US
Telephone Number	:	304-720-9595
Fax Number	:

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

Provider Enumeration Date	:	01/13/2023
Last Update Date	:	03/04/2026

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Directions to “ ANGEL JACKSON ” Practice Location

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