Provider Demographics
NPI:1508204231
Name:MILLER, JARED (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 B ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3547
Mailing Address - Country:US
Mailing Address - Phone:208-200-3650
Mailing Address - Fax:
Practice Address - Street 1:320 B ST
Practice Address - Street 2:SUITE 110
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3547
Practice Address - Country:US
Practice Address - Phone:208-200-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID296991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical