Individual
JENNIFER R JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CPNP
Contact information
Practice address
15901 BASS RD STE 102, FORT MYERS, FL 33908-3838
(239) 343-9890
(239) 343-9898
Mailing address
PO BOX 2147, FORT MYERS, FL 33902-2147
(239) 343-9890
(239) 343-9898
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
28148319A
IN
363LP0200X
Pediatric Nurse Practitioner
71004791A
IN
363LP0200X
Pediatric Nurse Practitioner
Primary
APRN11019090
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
113907600
—
FL
Enumeration date
12/18/2013
Last updated
05/03/2022
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