JENNIFER R JACK CPNP
NPI 1184045148
Nurse Practitioner - Pediatrics in Fort Myers, FL

Q: What is Jennifer Jack's NPI number?

The NPI number for Jennifer Jack is 1184045148. It was assigned to this individual provider in the NPPES registry on December 18, 2013. The provider is also known as Jennifer R Wallace.

Q: What is Jennifer Jack's specialty?

The primary specialty registered for this NPI is Nurse Practitioner, specializing in Pediatrics, with taxonomy code 363LP0200X.

Q: When was this NPI record last updated?

The NPPES record for Jennifer Jack was last updated on May 3, 2022. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 4 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since December 18, 2013PECOS Enrolled

15901 BASS RD STE 102, FORT MYERS, FL 33908(239) 343-9890(239) 343-9898 Get Directions Write a Review

NPPES record last updated: May 3, 2022. Verified against the NPPES registry weekly; last sync: October 25, 2026.

Record update history: May 3, 2022, Apr 13, 2022, Jan 12, 2021 and 1 more (4 updates tracked since 2018).

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About Jennifer R Jack Cpnp NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

JENNIFER R JACK CPNP (NPI 1184045148) is an individual pediatrics provider in Fort Myers, Florida, licensed in Florida (APRN11019090) and active in the NPI registry since December 2013. She is enrolled in Medicare PECOS.

NPPES Registry Identity

NPI1184045148

Entity TypeIndividualFemale

Primary Taxonomy363LP0200X

Provider Legal NameJENNIFER R JACKCredential: CPNP

Location Address15901 BASS RD STE 102Fort Myers, FL 33908-3838

Mailing AddressPo Box 2147Fort Myers, FL 33902-2147 · (239) 343-9890 · Fax (239) 343-9898

Phone(239) 343-9890

Fax(239) 343-9898

Sole ProprietorNo

Enumeration DateDecember 18, 2013

Last NPPES UpdateMay 3, 20224 updates tracked since enumeration

NPPES CertifiedMay 3, 2022

✔ NPI 1184045148 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyNurse Practitioner · PediatricsPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363LP0200X

Licenses✔ Licensed in FL · APRN11019090✔ Licensed in IN · 28148319A✔ Licensed in IN · 71004791A

15901 BASS RD STE 102, Fort Myers, FL 33908

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Other Names 1

Former Name (1)Jennifer R Wallace

Other Identifiers 1

Medicaid113907600FL

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Ambetter from Superior HealthPlan, Ambetter Health, Ambetter of Alabama and more.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Jennifer R Jack Cpnp is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Medicare Billing Reassignments

Medicare enrollment records show Jennifer Jack reassigns Medicare billing to 2 organizations. Each organization bills Medicare for the services this provider delivers there; the nearest is listed first.

Lee Health System Inc

0.3 mi

Internal Medicine

9981 S HEALTHPARK DR
Fort Myers, FL 33908

Reassigned Medicare billing, Florida enrollment
1,899 clinicians in this Medicare group

NPI 1942058557 (239) 424-1500

Lee Memorial Health System

0.3 mi

Internal Medicine

9981 S HEALTHPARK DR
Fort Myers, FL 33908

Reassigned Medicare billing, Florida enrollment
1,345 clinicians in this Medicare group

NPI 1992873319 (239) 424-1500

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 33908 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$91.69 typical visit price

range $58.56 – $179.05

Typical copayment $22.92 (range $14.64 – $44.76)

Most-billed visit code 99203

Established Patient

$103.21 typical visit price

range $18.44 – $144.68

Typical copayment $25.80 (range $4.61 – $36.17)

Most-billed visit code 99214

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES 15

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

CAYCE JEHAIMI M.D.

Pediatrics (Pediatric Endocrinology)