Provider Demographics
NPI:1750309332
Name:MILLER, JACKY ADAM (DNP,FAWM)
Entity Type:Individual
Prefix:DR
First Name:JACKY
Middle Name:ADAM
Last Name:MILLER
Suffix:
Gender:M
Credentials:DNP,FAWM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2095 N DOLORES RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-8924
Mailing Address - Country:US
Mailing Address - Phone:970-564-8086
Mailing Address - Fax:
Practice Address - Street 1:2095 N DOLORES RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-8924
Practice Address - Country:US
Practice Address - Phone:970-564-8086
Practice Address - Fax:970-564-8087
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR51146363LA2100X
CO167292363LA2100X
TX624662363LA2100X
NC5008214363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care