Provider Demographics
NPI:1184045148
Name:JACK, JENNIFER R (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:JACK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:WALLACE
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:239-343-9890
Mailing Address - Fax:239-343-9898
Practice Address - Street 1:15901 BASS RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3838
Practice Address - Country:US
Practice Address - Phone:239-343-9890
Practice Address - Fax:239-343-9898
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28148319A363LP0200X
IN71004791A363LP0200X
FLAPRN11019090363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113907600Medicaid