Provider Demographics
NPI:1699456764
Name:MILLER, JENNIFER R (PHD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:R
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-2634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 W 72ND ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3204
Practice Address - Country:US
Practice Address - Phone:212-799-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025852103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical