Provider Demographics
NPI:1992240626
Name:MILLER, JACKSON A (MAC, LAC)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7907 VALLEY MANOR RD
Mailing Address - Street 2:UNIT F
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5335
Mailing Address - Country:US
Mailing Address - Phone:443-604-4157
Mailing Address - Fax:
Practice Address - Street 1:6302 FALLS RD
Practice Address - Street 2:SUITE C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2038
Practice Address - Country:US
Practice Address - Phone:443-604-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02388171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD81-4494780OtherEIN