Provider Demographics
NPI:1134583529
Name:MILLER, JASON TODD (MED, ATC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TODD
Last Name:MILLER
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 DUTCH LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-5523
Mailing Address - Country:US
Mailing Address - Phone:662-425-4545
Mailing Address - Fax:
Practice Address - Street 1:65 DUTCH LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-5523
Practice Address - Country:US
Practice Address - Phone:662-425-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT5492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer