Provider Demographics
NPI:1104992379
Name:MILLER, JERRALD C (DC)
Entity type:Individual
Prefix:DR
First Name:JERRALD
Middle Name:C
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1309
Mailing Address - Country:US
Mailing Address - Phone:952-378-1813
Mailing Address - Fax:952-378-1826
Practice Address - Street 1:135 1ST AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1309
Practice Address - Country:US
Practice Address - Phone:952-378-1813
Practice Address - Fax:952-378-1826
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4822111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor