Provider Demographics
NPI:1972883585
Name:MILLER, JENNIFER LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:127 OLD FARM MIDDLE CT
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1485
Mailing Address - Country:US
Mailing Address - Phone:815-937-4333
Mailing Address - Fax:815-936-1014
Practice Address - Street 1:222 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3711
Practice Address - Country:US
Practice Address - Phone:815-936-0817
Practice Address - Fax:815-936-1014
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051-037876OtherREGISTERED PHARMACIST