Provider Demographics
NPI:1174182778
Name:MILLER, JORDAN R (LAC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5359 E ELMWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5440
Mailing Address - Country:US
Mailing Address - Phone:480-528-1784
Mailing Address - Fax:
Practice Address - Street 1:3048 E BASELINE RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7287
Practice Address - Country:US
Practice Address - Phone:480-452-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-6046T101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor