Healthcare Provider Details

I. General information

NPI: 1477462810
Provider Name (Legal Business Name): JENNIFER LYNN MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S MESA DR
MESA AZ
85210-2546
US

IV. Provider business mailing address

640 S MESA DR
MESA AZ
85210-2546
US

V. Phone/Fax

Practice location:
  • Phone: 602-525-6863
  • Fax:
Mailing address:
  • Phone: 602-525-6863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberD00147564
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: