Provider Demographics
NPI:1144763301
Name:CALLAHAN, JERI (APRN)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9470
Mailing Address - Fax:239-343-9498
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9470
Practice Address - Fax:239-343-9498
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA020211363LF0000X
FLAPRN11002574363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103431200Medicaid