Provider Demographics
NPI:1083135321
Name:MILLER, JESSICA RAE (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2467
Mailing Address - Country:US
Mailing Address - Phone:618-843-5745
Mailing Address - Fax:
Practice Address - Street 1:300 S SCOTT AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-1658
Practice Address - Country:US
Practice Address - Phone:618-783-2309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist