Provider Demographics
NPI:1437912557
Name:MILLER, JESSICA NICHOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLE
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:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-0517
Mailing Address - Country:US
Mailing Address - Phone:801-821-9348
Mailing Address - Fax:
Practice Address - Street 1:193 S MORGAN VALLEY DR
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9668
Practice Address - Country:US
Practice Address - Phone:801-821-9348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13777837-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant