Provider Demographics
NPI:1376601153
Name:MILLER, JESSICA LANIER
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LANIER
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3389
Mailing Address - Country:US
Mailing Address - Phone:678-377-2833
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340247OtherWELLCARE-AAKTS
GA147217028AMedicaid
GA10062648OtherAMERIGROUP-AAKTS