Provider Demographics
NPI:1942581558
Name:MILLER, JESSICA L (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7519 RIVERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4662
Mailing Address - Country:US
Mailing Address - Phone:843-735-5080
Mailing Address - Fax:
Practice Address - Street 1:7519 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4662
Practice Address - Country:US
Practice Address - Phone:843-735-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054783363A00000X
OH50.004225363A00000X
SC2597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115927Medicaid
OHH426230Medicare PIN
OH0115927Medicaid