MEDICARE: CLAUDETTE F JACKSON PAC

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	363A00000X	Physician Assistant	PA9109552	FL
2	363A00000X	Physician Assistant	PA902	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00706704	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000595343	OTHER	KY	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962494450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLAUDETTE F JACKSON PAC

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-343-1100
Fax Number	:	239-343-1101

Provider Business Practice Location Address
First Line	:	13782 PLANTATION RD STE 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4462
Country	:	US
Telephone Number	:	239-343-1100
Fax Number	:	239-343-1101

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	04/18/2022

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Practice Location Address:

13782 PLANTATION RD STE 201
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33912-4462

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1598765372 — DR. JON BRILLMAN MD
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1114928009 — DR. HARRIS L BONNETTE M.D.
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33912-4462

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1376544775 — JOSEPH HOBSON D.O.
Practice Location Address:

13782 PLANTATION RD , SUITE 201
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33912-4462

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1528045747 — DR. BRIAN DANIEL KURLAND M.D.
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13782 PLANTATION RD , UNIT103
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1154396661 — MR. CHRISTOPHER ALFONSO MALLARI PA-C
Practice Location Address:

13782 PLANTATION RD , BUILDING 4, SUITE 201
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33912-4462

Practice Phone: 239-343-1105
Practice Fax: 239-343-1106

Directions to “ CLAUDETTE F JACKSON PAC” Practice Location

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