Provider Demographics
NPI:1407130198
Name:MILLER, JACK LAWRENCE (LMT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LAWRENCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8936 N ONYX ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9415
Mailing Address - Country:US
Mailing Address - Phone:520-668-6306
Mailing Address - Fax:
Practice Address - Street 1:7620 N HARTMAN LN STE 184
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-7485
Practice Address - Country:US
Practice Address - Phone:520-668-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-13827225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist