Provider Demographics
NPI:1669823068
Name:JACKSON, KORY (NP)
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KORY
Other - Middle Name:
Other - Last Name:MAYO
Other - Suffix:
Other - Last Name Type:Former Name
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:239-343-0629
Mailing Address - Fax:239-343-0625
Practice Address - Street 1:13685 DOCTORS WAY STE 170
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-0629
Practice Address - Fax:239-343-0625
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014384363LG0600X
FLAPRN11024568363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118448900Medicaid