Provider Demographics
NPI:1770871063
Name:MILLER, JESSICA MARIE (DPT)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HARBOR BEND CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1478
Mailing Address - Country:US
Mailing Address - Phone:636-697-6964
Mailing Address - Fax:
Practice Address - Street 1:2 HARBOR BEND CT
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1478
Practice Address - Country:US
Practice Address - Phone:636-697-6964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist