Provider Demographics
NPI:1164598892
Name:MILLER, JAKE
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:IBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 PARMAC RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2294
Mailing Address - Country:US
Mailing Address - Phone:530-879-3950
Mailing Address - Fax:530-879-3949
Practice Address - Street 1:564 RIO LINDO AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1852
Practice Address - Country:US
Practice Address - Phone:530-879-3950
Practice Address - Fax:530-879-3949
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)