Provider Demographics
NPI:1093330714
Name:JACKSON, RENUKA
Entity Type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENUKA
Other - Middle Name:
Other - Last Name:PUNWASI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:6150 DIAMOND CENTRE CT UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4367
Mailing Address - Country:US
Mailing Address - Phone:239-561-9191
Mailing Address - Fax:
Practice Address - Street 1:6150 DIAMOND CENTRE CT UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4367
Practice Address - Country:US
Practice Address - Phone:239-561-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner