Provider Demographics
NPI:1962172627
Name:MILLER, JENNIFER FAE (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6914 OLD PORTER CT APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1779
Mailing Address - Country:US
Mailing Address - Phone:219-331-4305
Mailing Address - Fax:
Practice Address - Street 1:CALUMET HIGH SCHOOL
Practice Address - Street 2:3900 CALHOUN ST., DOOR R
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408
Practice Address - Country:US
Practice Address - Phone:219-240-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009407A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical