Provider Demographics
NPI:1922549567
Name:MILLER, JACKIE L (LPC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
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 1:1517 E HUEBBE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1795
Mailing Address - Country:US
Mailing Address - Phone:608-291-5891
Mailing Address - Fax:608-713-9040
Practice Address - Street 1:1517 E HUEBBE PKWY STE A
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1795
Practice Address - Country:US
Practice Address - Phone:608-291-5891
Practice Address - Fax:608-713-9040
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2020-04-09
Deactivation Date:2019-02-14
Deactivation Code:
Reactivation Date:2019-02-22
Provider Licenses
StateLicense IDTaxonomies
WI7632-125101YM0800X, 101YP2500X
WINA131596376K00000X, 376K00000X
WI3482-226171M00000X, 251B00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100086806Medicaid