Healthcare Provider Details

I. General information

NPI: 1861803488
Provider Name (Legal Business Name): MR. JEFFERY MATTHEW MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 GOLDEN LN
FALLBROOK CA
92028-3447
US

IV. Provider business mailing address

711 GOLDEN LN
FALLBROOK CA
92028-3447
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 18545
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: