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NPI Code Detail

MEDICARE: KORY JACKSON NP

MEDICARE: KORY JACKSON NP
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
1363LG0600XGerontology Nurse Practitioner209014384IL
2363LG0600XGerontology Nurse PractitionerAPRN11024568FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1669823068
Entity Type Code : Individual
Provider Name (Legal Business Name) : KORY JACKSON NP
Provider Business Mailing Address
First Line : PO BOX 2147
Second Line :
City : FORT MYERS
State : FL
Zip : 33902-2147
Country : US
Telephone Number : 239-343-0629
Fax Number : 239-343-0625
Provider Business Practice Location Address
First Line : 13685 DOCTORS WAY STE 170
Second Line :
City : FORT MYERS
State : FL
Zip : 33912-4337
Country : US
Telephone Number : 239-343-0629
Fax Number : 239-343-0625
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/27/2016
Last Update Date : 07/14/2023

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