Provider Demographics
NPI:1720586688
Name:MILES, JENNIFER (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9551 171ST ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-6109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9551 171ST ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-6109
Practice Address - Country:US
Practice Address - Phone:866-395-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018491363LF0000X
MI4704302022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily