Provider Demographics
NPI:1033712617
Name:MILLER, JAKE EDWARDS (RN)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:EDWARDS
Last Name:MILLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-6316
Mailing Address - Country:US
Mailing Address - Phone:401-559-3250
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:617-323-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC289068163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse