Basic Information
| Provider Information | |||||||||
| NPI: | 1619311396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2237 LITHIA CENTER LN | ||||||||
| Address2: | |||||||||
| City: | VALRICO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335965676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136620123 | ||||||||
| FaxNumber: | 8136629422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | UO3361 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2854 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS12374 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | L4606 | 01 | FL | MEDICARE | OTHER | HJ9SR | 01 | FL | BCBS | OTHER | 023417500 | 05 | FL | MEDICAID |