Provider Demographics
NPI:1558362715
Name:MILLER, JENNIFER LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:
Practice Address - Street 1:2155 W ORANGE GROVE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3118
Practice Address - Country:US
Practice Address - Phone:520-742-0414
Practice Address - Fax:520-742-6635
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1349207Q00000X
AZ3606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H54457Medicare UPIN