Provider Demographics
NPI:1316585219
Name:JACKSON, CERRA JORDAN (CRNP)
Entity Type:Individual
Prefix:
First Name:CERRA
Middle Name:JORDAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 WATERMELON ROAD SUITE 600
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473
Mailing Address - Country:US
Mailing Address - Phone:205-345-6272
Mailing Address - Fax:
Practice Address - Street 1:5710 WATERMELON ROAD, SUITE 600
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-143406207Q00000X, 364SF0001X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health