Provider Demographics
NPI:1205033925
Name:MILLER, JESSIE (DC)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:BEUKEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:904 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4705 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4103
Practice Address - Country:US
Practice Address - Phone:386-763-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor