Provider Demographics
NPI:1063922201
Name:MILLER, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3774 S SUNNYVALE DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3142
Mailing Address - Country:US
Mailing Address - Phone:918-924-8160
Mailing Address - Fax:
Practice Address - Street 1:3774 S SUNNYVALE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-3142
Practice Address - Country:US
Practice Address - Phone:918-924-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker