Provider Demographics
NPI:1295774784
Name:JACKOWSKI, JOYCE A (ARNP)
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:A
Last Name:JACKOWSKI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-7820
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:714 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-3992
Practice Address - Country:US
Practice Address - Phone:941-460-1300
Practice Address - Fax:941-460-1306
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168707363L00000X
OHNP07980363L00000X
FLARNP9396947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000391441OtherANTHEM
OH2519984Medicaid
Q28553Medicare UPIN