Provider Demographics
NPI:1306286695
Name:MILLER, JENNA L (SLP-CF)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 SUNNYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5997
Mailing Address - Country:US
Mailing Address - Phone:208-731-2689
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W STE 3802
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5811
Practice Address - Country:US
Practice Address - Phone:208-814-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-2418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist