MEDICARE: LEE DOUGLAS JACKSON NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP60602473	WA
2	363L00000X	Nurse Practitioner	AP60602473	WA
3	363LF0000X	Family Nurse Practitioner	2011003377	MO
4	363LF0000X	Family Nurse Practitioner	APRN11027444	FL
5	363LF0000X	Family Nurse Practitioner	5375350071	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053602102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE DOUGLAS JACKSON NP-C

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-343-9100
Fax Number	:	239-343-9108

Provider Business Practice Location Address
First Line	:	16271 BASS RD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3616
Country	:	US
Telephone Number	:	239-343-7100
Fax Number	:	239-468-7924

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2011
Last Update Date	:	05/27/2026

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