Provider Demographics
NPI:1083308605
Name:MILLER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5973 GRAND PAVILION WAY UNIT 409
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-2294
Mailing Address - Country:US
Mailing Address - Phone:607-376-6809
Mailing Address - Fax:
Practice Address - Street 1:5973 GRAND PAVILION WAY UNIT 409
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22303-2294
Practice Address - Country:US
Practice Address - Phone:607-376-6809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant