Provider Demographics
NPI:1437494804
Name:DR. MEGHAN JACKSON MILLER PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:DR. MEGHAN JACKSON MILLER PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:917-992-1569
Mailing Address - Street 1:68 E HARTSDALE AVE
Mailing Address - Street 2:APT 3L
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-2710
Mailing Address - Country:US
Mailing Address - Phone:917-992-1569
Mailing Address - Fax:718-329-0267
Practice Address - Street 1:1560 PELHAM PKWY S
Practice Address - Street 2:SUITE 1C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1114
Practice Address - Country:US
Practice Address - Phone:917-992-1569
Practice Address - Fax:718-329-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100120886Medicare PIN