Provider Demographics
NPI:1003483777
Name:MILLER, GENNI LEE (LAT, ATC, PTA)
Entity Type:Individual
Prefix:
First Name:GENNI
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LAT, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 COUNTY ROAD 1518
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-6593
Mailing Address - Country:US
Mailing Address - Phone:903-724-3232
Mailing Address - Fax:
Practice Address - Street 1:1210 CORINTH RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-3208
Practice Address - Country:US
Practice Address - Phone:903-586-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT12562081S0010X
TX2076630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant