Provider Demographics
NPI:1427187780
Name:MILLER, JENNIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:720-336-3989
Practice Address - Street 1:16570 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80023-8964
Practice Address - Country:US
Practice Address - Phone:303-689-6600
Practice Address - Fax:303-689-6601
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2314OtherCOLORADO
COC811417Medicare PIN