Provider Demographics
NPI:1740053263
Name:MILLER, JESSICA (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 BENJAMIN ST NE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4808
Mailing Address - Country:US
Mailing Address - Phone:612-220-4872
Mailing Address - Fax:
Practice Address - Street 1:6 E DIAMOND LAKE RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1923
Practice Address - Country:US
Practice Address - Phone:612-552-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPENDING103TC0700X
MNLP7060103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty