Provider Demographics
NPI:1518178771
Name:MILES, JACQUELINE RUSSIANO (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:RUSSIANO
Last Name:MILES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3568 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-4616
Mailing Address - Country:US
Mailing Address - Phone:626-440-9974
Mailing Address - Fax:626-440-9979
Practice Address - Street 1:745 S MARENGO AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-4735
Practice Address - Country:US
Practice Address - Phone:626-577-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7882103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist