Provider Demographics
NPI:1326528415
Name:MILLER, JACLYN (NP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:CT
Mailing Address - Zip Code:06444-0440
Mailing Address - Country:US
Mailing Address - Phone:203-565-4190
Mailing Address - Fax:
Practice Address - Street 1:710 MAIN ST BLDG 1
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1568
Practice Address - Country:US
Practice Address - Phone:860-276-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily