Provider Demographics
NPI:1003875311
Name:MILLER, JACKIE L (HADE, HIS)
Entity Type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:HADE, HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 ALBERMARLE DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5912
Mailing Address - Country:US
Mailing Address - Phone:423-842-1396
Mailing Address - Fax:423-842-0221
Practice Address - Street 1:4110 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3700
Practice Address - Country:US
Practice Address - Phone:423-622-0087
Practice Address - Fax:423-622-7300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN561237700000X
GA687237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist