Provider Demographics
NPI:1770994766
Name:JACKSON, ANGALENE DEAPEN (DO)
Entity type:Individual
Prefix:
First Name:ANGALENE
Middle Name:DEAPEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:DEAPEN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2800 E BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6410
Mailing Address - Country:US
Mailing Address - Phone:682-518-1035
Mailing Address - Fax:682-518-1045
Practice Address - Street 1:2800 E BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6410
Practice Address - Country:US
Practice Address - Phone:682-518-1035
Practice Address - Fax:682-518-1045
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VIQ9384207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology