Provider Demographics
NPI:1154455459
Name:MILLER, JENNIFER L (LISW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 KENYON RD STE C
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5718
Mailing Address - Country:US
Mailing Address - Phone:515-573-3138
Mailing Address - Fax:515-573-3130
Practice Address - Street 1:7177 HICKMAN RD STE 3
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50322-4844
Practice Address - Country:US
Practice Address - Phone:515-251-4900
Practice Address - Fax:515-251-7311
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI9565004Medicare UPIN