Provider Demographics
NPI:1992790117
Name:MILLER, JONATHAN M (PHD LP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3327
Mailing Address - Country:US
Mailing Address - Phone:651-728-0922
Mailing Address - Fax:
Practice Address - Street 1:2113 CLIFF DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3327
Practice Address - Country:US
Practice Address - Phone:651-728-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4000103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN228524000Medicaid