Provider Demographics
NPI:1235207069
Name:MILLER, JEFFREY R (LIC AC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 SYCAMORE ST
Mailing Address - Street 2:#7
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-3720
Mailing Address - Country:US
Mailing Address - Phone:774-991-1068
Mailing Address - Fax:
Practice Address - Street 1:PATHWAYS TO WELLNESS
Practice Address - Street 2:142 BERKELEY STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:774-991-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209753171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist