Provider Demographics
NPI:1245308048
Name:PAYNE, JACQUELINE (DO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-656-6765
Practice Address - Street 1:3571 DEL PRADO BLVD N STE 2
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5287
Practice Address - Country:US
Practice Address - Phone:239-656-6300
Practice Address - Fax:239-656-6765
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099212Medicaid
IN200258980Medicaid