Provider Demographics
NPI:1962494450
Name:JACKSON, CLAUDETTE F (PAC)
Entity Type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PAC
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:239-343-1100
Mailing Address - Fax:239-343-1101
Practice Address - Street 1:13782 PLANTATION RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4462
Practice Address - Country:US
Practice Address - Phone:239-343-1100
Practice Address - Fax:239-343-1101
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109552363A00000X
KYPA902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000595343OtherBCBS
FL113774800Medicaid
KYP00706704OtherRAILROAD MEDICARE
KY000000595343OtherBCBS