Provider Demographics
NPI:1215138821
Name:MILLER, JEANNINE ANTOINNETTE (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JEANNINE
Middle Name:ANTOINNETTE
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 1:402 E SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7133
Mailing Address - Country:US
Mailing Address - Phone:520-297-7416
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-1656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0473235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP0473OtherSTATE LICENSE