Provider Demographics
NPI:1356611594
Name:MILLER, JESSICA LYNNE (NCMTB)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:NCMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 CENTER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-8480
Mailing Address - Country:US
Mailing Address - Phone:610-308-7738
Mailing Address - Fax:
Practice Address - Street 1:11150 HURON ST
Practice Address - Street 2:SUITE 212
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4379
Practice Address - Country:US
Practice Address - Phone:303-952-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO605464-11172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker