MEDICARE: ANGELICA JACKSON PA-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	363AM0700X	Medical Physician Assistant	PA11392	TX
2	363AM0700X	Medical Physician Assistant	0010-05899	NC

General Provider Information

NPI Number	:	1770950305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA JACKSON PA-C

Provider Business Mailing Address
First Line	:	4706 SABERO LN
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4893
Country	:	US
Telephone Number	:	951-970-7201
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 CLEAR LK CTY BLVD STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062-8069
Country	:	US
Telephone Number	:	713-493-1346
Fax Number	:

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

Provider Enumeration Date	:	08/31/2015
Last Update Date	:	04/29/2024

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