Healthcare Provider Details

I. General information

NPI: 1164598892
Provider Name (Legal Business Name): MR. JAKE MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JAKE IBSEN

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 RIO LINDO AVE SUITE 204
CHICO CA
95926-1852
US

IV. Provider business mailing address

109 PARMAC RD SUITE 1
CHICO CA
95926-2294
US

V. Phone/Fax

Practice location:
  • Phone: 530-879-3950
  • Fax: 530-879-3949
Mailing address:
  • Phone: 530-879-3950
  • Fax: 530-879-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: