Provider Demographics
NPI:1750625463
Name:MCMILLON, JERICO PAGE (BA, CACIII)
Entity type:Individual
Prefix:MS
First Name:JERICO
Middle Name:PAGE
Last Name:MCMILLON
Suffix:
Gender:F
Credentials:BA, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 LIPAN ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80260-4912
Mailing Address - Country:US
Mailing Address - Phone:303-412-3823
Mailing Address - Fax:
Practice Address - Street 1:8801 LIPAN ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-4912
Practice Address - Country:US
Practice Address - Phone:303-412-3823
Practice Address - Fax:303-412-3430
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)