Healthcare Provider Details

I. General information

NPI: 1184270381
Provider Name (Legal Business Name): JESSICA NICOLE MILLAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5887 BROCKTON AVE
RIVERSIDE CA
92506-1853
US

IV. Provider business mailing address

8782 BARTON ST
RIVERSIDE CA
92508-3224
US

V. Phone/Fax

Practice location:
  • Phone: 951-275-8500
  • Fax:
Mailing address:
  • Phone: 909-213-9859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95012108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: