Provider Demographics
NPI:1316255235
Name:MILLER, JESSICA (RD CDE CDN)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD CDE CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 CRESCENT ST
Mailing Address - Street 2:APARTMENT D7
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2114 CRESCENT ST
Practice Address - Street 2:APARTMENT D7
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3359
Practice Address - Country:US
Practice Address - Phone:484-437-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48006371133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered