Provider Demographics
NPI:1821393711
Name:MIILU, JEANNE KAY (LLMSW)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:KAY
Last Name:MIILU
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:KAY
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-2369
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:114 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5124
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-313-8234
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6801092771104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor