Provider Demographics
NPI:1659929123
Name:CZAJKA, JACOB MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MARK
Last Name:CZAJKA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:239-343-9800
Mailing Address - Fax:239-343-9848
Practice Address - Street 1:4771 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1317
Practice Address - Country:US
Practice Address - Phone:239-343-9800
Practice Address - Fax:239-343-9848
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010457363A00000X
NY363AS0400X
FLPA9115985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115551000Medicaid
MIC200356585308OtherMICHIGAN STATE LICENSE
MIC200356585308OtherSTATE LICENSE