Provider Demographics
NPI:1215963152
Name:MILLER, JEAN ANN (DIETITIAN)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-0849
Mailing Address - Country:US
Mailing Address - Phone:405-273-5801
Mailing Address - Fax:405-878-3814
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:405-878-3814
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100631540CMedicaid
OK100631540CMedicaid