Individual
JACLYN WISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
9617 GULF RESEARCH LN, FORT MYERS, FL 33912-4560
(239) 418-0999
(239) 418-0091
Mailing address
953 TIDALWALK DR, WILMINGTON, NC 28409-4968
(239) 738-4935
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-11679
NC
363A00000X
Physician Assistant
PA9105690
FL
363A00000X
Physician Assistant
Primary
PA9120414
FL
363A00000X
Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
016281900
—
FL
Enumeration date
12/07/2010
Last updated
01/28/2026
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