Provider Demographics
NPI:1992493407
Name:MILLER, JONATHAN EDWARD
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SW 62ND BLVD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3895
Mailing Address - Country:US
Mailing Address - Phone:402-560-8089
Mailing Address - Fax:402-560-8089
Practice Address - Street 1:1000 SW 62ND BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-3895
Practice Address - Country:US
Practice Address - Phone:402-560-8089
Practice Address - Fax:402-560-8089
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23270167106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician