Provider Demographics
NPI:1083656979
Name:MILLER, JENNIFER E (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:312-695-0665
Mailing Address - Fax:312-695-6594
Practice Address - Street 1:1704 MAPLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3134
Practice Address - Country:US
Practice Address - Phone:312-694-2273
Practice Address - Fax:312-694-2299
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085002629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ68704Medicare UPIN
ILK27451Medicare ID - Type Unspecified