Provider Demographics
NPI:1700547148
Name:MILLER, JESSIE ANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ANNA
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2450
Mailing Address - Country:US
Mailing Address - Phone:309-692-6622
Mailing Address - Fax:309-692-6952
Practice Address - Street 1:6615 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2450
Practice Address - Country:US
Practice Address - Phone:309-692-6622
Practice Address - Fax:309-692-6952
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0240801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical