Provider Demographics
NPI:1407081862
Name:COLLADO, JERRY C (CFNP)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:COLLADO
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM SUITE 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-9528
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:6919 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1268
Practice Address - Country:US
Practice Address - Phone:601-956-0911
Practice Address - Fax:601-957-8439
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I502230OtherMEDICARE PTAN
MS302I508596Medicare PIN
MS302I508612Medicare PIN