Provider Demographics
NPI:1710981378
Name:MILLER, JESSE D (PT, MS, ECS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:D
Last Name:MILLER
Suffix:
Gender:M
Credentials:PT, MS, ECS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2696
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0048
Mailing Address - Country:US
Mailing Address - Phone:706-258-7253
Mailing Address - Fax:
Practice Address - Street 1:129 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-3435
Practice Address - Country:US
Practice Address - Phone:706-896-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6124225100000X
GA6473225100000X
NC8554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000848537AMedicaid
TN3652413Medicaid
TN3652413Medicare ID - Type Unspecified
GA000848537AMedicaid