Provider Demographics
NPI:1659818631
Name:MILLER, JACQUELINE RENE (ATC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENE
Last Name:MILLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 E HAMPTON AVE APT 1137
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3453
Mailing Address - Country:US
Mailing Address - Phone:209-543-2272
Mailing Address - Fax:
Practice Address - Street 1:2610 ASSOCIATED RD
Practice Address - Street 2:APT A4
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:209-543-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program