Provider Demographics
NPI:1821442484
Name:MILLER, JORDAN (ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E PIKE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45065-1334
Mailing Address - Country:US
Mailing Address - Phone:513-806-7365
Mailing Address - Fax:
Practice Address - Street 1:324 E PIKE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45065-1334
Practice Address - Country:US
Practice Address - Phone:513-806-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT. 0042772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer