Healthcare Provider Details

I. General information

NPI: 1053602102
Provider Name (Legal Business Name): LEE DOUGLAS JACKSON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16271 BASS RD
FORT MYERS FL
33908-3616
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-7100
  • Fax: 239-468-7924
Mailing address:
  • Phone: 239-343-9100
  • Fax: 239-343-9108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11027444
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60602473
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011003377
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60602473
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5375350071
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: