Provider Demographics
NPI:1790232403
Name:MILLER, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MILLER
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 1:304 S 100 W APT 9
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-3269
Mailing Address - Country:US
Mailing Address - Phone:435-218-9526
Mailing Address - Fax:
Practice Address - Street 1:304 S 100 W APT 9
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3269
Practice Address - Country:US
Practice Address - Phone:435-218-9526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-10
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst