Provider Demographics
NPI:1790946820
Name:MILLER, JEAN SMITH (RPT)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:SMITH
Last Name:MILLER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5372B OLD VIRGINIA STREET
Mailing Address - Street 2:
Mailing Address - City:URBANNA
Mailing Address - State:VA
Mailing Address - Zip Code:23175
Mailing Address - Country:US
Mailing Address - Phone:804-758-5250
Mailing Address - Fax:804-758-5183
Practice Address - Street 1:5372B OLD VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:804-758-5183
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305000705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4978137Medicaid