MEDICARE: JOHNATHAN KEITH COLTON JERRIS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	10188	GA

General Provider Information

NPI Number	:	1093310021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN KEITH COLTON JERRIS PA

Provider Business Mailing Address
First Line	:	31 COVENTRY DR SE
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-8412
Country	:	US
Telephone Number	:	706-248-5048
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 BUCKHEAD AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-3063
Country	:	US
Telephone Number	:	404-400-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	03/26/2026

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