1093310021 NPI number — JOHNATHAN KEITH COLTON JERRIS PA

Table of content: DIANA ALICIA RIVERA-MALDONADO MASSAGE THERPIST (NPI 1720851322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093310021 NPI number — JOHNATHAN KEITH COLTON JERRIS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERRIS
Provider First Name:
JOHNATHAN
Provider Middle Name:
KEITH COLTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093310021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 BUCKHEAD AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30305-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-400-2800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  10188 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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