Provider Demographics
NPI:1609300102
Name:JACKSON, ANGEL (PMHNP)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:911 CENTRAL PKWY N STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5053
Mailing Address - Country:US
Mailing Address - Phone:800-404-6050
Mailing Address - Fax:866-313-3397
Practice Address - Street 1:5119 BECKWITH BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2277
Practice Address - Country:US
Practice Address - Phone:210-366-3700
Practice Address - Fax:210-265-1442
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1024242363LP0808X
TX13441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13441OtherTEXAS BOARD OF CHIROPRACTIC EXAMINERS
TX1024242OtherTEXAS BOARD OF NURSING