Provider Demographics
NPI:1093898603
Name:MILLER, JEFFREY (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W NC HIGHWAY 54 STE 103
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:919-748-4441
Practice Address - Street 1:3604 SHANNON RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707
Practice Address - Country:US
Practice Address - Phone:919-403-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0134761041C0700X
NCC0081941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA408262SADMedicare ID - Type UnspecifiedMEDICARE