Provider Demographics
NPI:1033760731
Name:MASON, JACLYN (APRN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18431 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3276
Mailing Address - Country:US
Mailing Address - Phone:239-989-3085
Mailing Address - Fax:
Practice Address - Street 1:18431 HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-3276
Practice Address - Country:US
Practice Address - Phone:239-989-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily