Healthcare Provider Details

I. General information

NPI: 1093310021
Provider Name (Legal Business Name): JOHNATHAN KEITH COLTON JERRIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BUCKHEAD AVE NE
ATLANTA GA
30305-3063
US

IV. Provider business mailing address

31 COVENTRY DR SE
ROME GA
30161-8412
US

V. Phone/Fax

Practice location:
  • Phone: 404-400-2800
  • Fax:
Mailing address:
  • Phone: 706-248-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10188
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: