Healthcare Provider Details

I. General information

NPI: 1912451709
Provider Name (Legal Business Name): JESSICA MILES M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4085 US HIGHWAY 1
ROCKLEDGE FL
32955-5307
US

IV. Provider business mailing address

2600 LARCH CIR NE APT 204
PALM BAY FL
32905-6439
US

V. Phone/Fax

Practice location:
  • Phone: 321-632-2737
  • Fax: 321-633-1963
Mailing address:
  • Phone: 321-632-2737
  • Fax: 321-633-1963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: