Provider Demographics
NPI:1164035192
Name:MILLER, JAYLENE
Entity Type:Individual
Prefix:
First Name:JAYLENE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 FAIRGROUNDS RD. TRL 36
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 FAIRGROUNDS RD. TRL 36
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-592-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician