Provider Demographics
NPI:1689617193
Name:MILLER, JEROME M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MAYNARD ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2440
Mailing Address - Country:US
Mailing Address - Phone:734-761-5347
Mailing Address - Fax:734-663-4327
Practice Address - Street 1:400 MAYNARD ST
Practice Address - Street 2:SUITE 503
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2440
Practice Address - Country:US
Practice Address - Phone:734-761-5347
Practice Address - Fax:734-663-4327
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0P30650Medicare ID - Type UnspecifiedMEDICARE