Provider Demographics
NPI:1942611579
Name:MILLER, JENNIFER KATHERINE (LPC-IT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:KATHERINE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-1207
Mailing Address - Country:US
Mailing Address - Phone:920-694-1264
Mailing Address - Fax:920-694-1299
Practice Address - Street 1:710 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4645
Practice Address - Country:US
Practice Address - Phone:920-694-1264
Practice Address - Fax:920-694-1299
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1668-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1668-226Medicaid