Healthcare Provider Details

I. General information

NPI: 1902320062
Provider Name (Legal Business Name): JERWANDA JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 W 3RD ST STE A
JACKSON GA
30233-1979
US

IV. Provider business mailing address

3333 RIVERWOOD PKWY SE STE 250
ATLANTA GA
30339-3304
US

V. Phone/Fax

Practice location:
  • Phone: 678-774-0430
  • Fax: 770-775-3410
Mailing address:
  • Phone: 770-914-0116
  • Fax: 770-955-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN220008
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN220008
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: