Provider Demographics
NPI:1417919457
Name:MILLER, JENNIFER L (PT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 4305
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6638
Mailing Address - Country:US
Mailing Address - Phone:315-329-7400
Mailing Address - Fax:315-329-7403
Practice Address - Street 1:4305 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 4305
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6638
Practice Address - Country:US
Practice Address - Phone:315-329-7400
Practice Address - Fax:315-329-7403
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB0033Medicare PIN