Provider Demographics
NPI:1053602102
Name:JACKSON, LEE DOUGLAS (NP-C)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:DOUGLAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:239-343-9100
Mailing Address - Fax:239-343-9108
Practice Address - Street 1:9131 COLLEGE POINTE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3245
Practice Address - Country:US
Practice Address - Phone:239-343-9100
Practice Address - Fax:239-343-9108
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60602473363L00000X, 363LF0000X
MO2011003377363LF0000X
KS5375350071363LF0000X
FLAPRN11027444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121013000Medicaid