Provider Demographics
NPI:1629108337
Name:MILLER, JEFFERY GOETZ (MA NCC LCPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:GOETZ
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA NCC LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 W GLEN AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-693-2749
Mailing Address - Fax:309-693-3894
Practice Address - Street 1:914 W GLEN AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-693-2749
Practice Address - Fax:309-693-3894
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional