Provider Demographics
NPI:1235611286
Name:BOBERG, JACQUELYN (APRN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:
Last Name:BOBERG
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 1:1561 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-6832
Mailing Address - Country:US
Mailing Address - Phone:239-440-9404
Mailing Address - Fax:
Practice Address - Street 1:737 CAPE CORAL PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8551
Practice Address - Country:US
Practice Address - Phone:239-542-0512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9345316363LF0000X
FLARNP9345316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty