Provider Demographics
NPI:1861001117
Name:MILLER, JACKIE CHARLENE (LPC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:CHARLENE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 12TH ST STE 911-D
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2462
Mailing Address - Country:US
Mailing Address - Phone:706-566-0805
Mailing Address - Fax:
Practice Address - Street 1:233 12TH ST STE 911-D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2462
Practice Address - Country:US
Practice Address - Phone:706-566-0805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
GALPC010997103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA196506062019Medicaid