Healthcare Provider Details

I. General information

NPI: 1982768339
Provider Name (Legal Business Name): JESSIE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD UNIT B
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6835
  • Fax: 415-473-4113
Mailing address:
  • Phone: 510-981-5290
  • Fax: 510-981-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF69198
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF69198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: