Provider Demographics
NPI:1104967322
Name:MILLER, JENNIFER (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 BASSWOOD BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4477
Mailing Address - Country:US
Mailing Address - Phone:817-498-0700
Mailing Address - Fax:817-498-0813
Practice Address - Street 1:5411 BASSWOOD BLVD
Practice Address - Street 2:SUITE 225
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4477
Practice Address - Country:US
Practice Address - Phone:817-498-0700
Practice Address - Fax:817-498-0813
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist