Provider Demographics
NPI:1619274867
Name:MILLER, JACK GLENN (CTN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:GLENN
Last Name:MILLER
Suffix:
Gender:M
Credentials:CTN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 N STOCKTON HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5190
Mailing Address - Country:US
Mailing Address - Phone:928-565-5853
Mailing Address - Fax:
Practice Address - Street 1:1308 N STOCKTON HILL RD STE A-153
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5139
Practice Address - Country:US
Practice Address - Phone:928-565-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
No175F00000XOther Service ProvidersNaturopath