Provider Demographics
NPI:1679105928
Name:MILLER, ADRIENNE JACKSON
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:JACKSON
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 THISTLE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-1104
Mailing Address - Country:US
Mailing Address - Phone:304-801-3258
Mailing Address - Fax:304-362-0025
Practice Address - Street 1:116 W PICCADILLY ST STE 12
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3956
Practice Address - Country:US
Practice Address - Phone:304-801-3258
Practice Address - Fax:304-362-0025
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician