Provider Demographics
NPI:1235257288
Name:MILLER, JERRY L (MA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:L
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:930 CAMBRIDGE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5356
Mailing Address - Country:US
Mailing Address - Phone:910-433-2307
Mailing Address - Fax:
Practice Address - Street 1:930 CAMBRIDGE ST STE 107
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5356
Practice Address - Country:US
Practice Address - Phone:910-433-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107454Medicaid