Provider Demographics
NPI:1104900653
Name:MILLER, JENNIFER K (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:MILLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18246 N 15TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-1278
Mailing Address - Country:US
Mailing Address - Phone:505-480-6926
Mailing Address - Fax:
Practice Address - Street 1:1930 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7518
Practice Address - Country:US
Practice Address - Phone:480-456-0719
Practice Address - Fax:480-456-0163
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ144506Medicaid