Basic Information
| Provider Information | |||||||||
| NPI: | 1114373131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | JULIAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | MC CA410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 E PARK AVE STE 112 | ||||||||
| Address2: | |||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168036706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
| FaxNumber: | 8148637803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 84645 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207QS0010X | MD479129 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.