Basic Information
| Provider Information | |||||||||
| NPI: | 1093927543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2546 E CAMINO ST | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852137725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806441703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25615 N RANCH GATE RD | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852552141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805027726 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP1427 | AZ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 721755 | 01 | AZ | AHCCCS NUMBER | OTHER |