Provider Demographics
NPI:1962963504
Name:MILLER, JEFFERY LUKE (COTA/L, ATP)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:LUKE
Last Name:MILLER
Suffix:
Gender:M
Credentials:COTA/L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 HIGHWAY 126
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-4525
Mailing Address - Country:US
Mailing Address - Phone:423-844-0939
Mailing Address - Fax:
Practice Address - Street 1:100 NETHERLAND LN
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7245
Practice Address - Country:US
Practice Address - Phone:423-245-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN01231224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant