Healthcare Provider Details

I. General information

NPI: 1013527811
Provider Name (Legal Business Name): JACKSON JAMES CERVI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE STE 705
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

74 MONTCLAIR DR NE
ATLANTA GA
30309-1527
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-0743
  • Fax:
Mailing address:
  • Phone: 678-656-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014802
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT014802
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: