Healthcare Provider Details

I. General information

NPI: 1316585219
Provider Name (Legal Business Name): CERRA JORDAN JACKSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22335 US HIGHWAY 72 STE C
ATHENS AL
35613-2611
US

IV. Provider business mailing address

22335 US HIGHWAY 72 STE C
ATHENS AL
35613-2611
US

V. Phone/Fax

Practice location:
  • Phone: 256-870-4111
  • Fax:
Mailing address:
  • Phone: 256-870-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1-143406
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number1-143406
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-143406
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: