Provider Demographics
NPI:1689022774
Name:MILES, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 BROADWAY CMNS
Mailing Address - Street 2:704
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-5871
Mailing Address - Country:US
Mailing Address - Phone:214-448-9475
Mailing Address - Fax:
Practice Address - Street 1:629 BROADWAY CMNS
Practice Address - Street 2:704
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5871
Practice Address - Country:US
Practice Address - Phone:214-448-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other