Provider Demographics
NPI:1497532881
Name:DORSCH, JACQUELINE TAYLOR
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TAYLOR
Last Name:DORSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 ANTICA ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-1500
Mailing Address - Country:US
Mailing Address - Phone:804-241-2574
Mailing Address - Fax:
Practice Address - Street 1:4790 BARKLEY CIR STE A
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7593
Practice Address - Country:US
Practice Address - Phone:239-275-8882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9117817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant