Healthcare Provider Details

I. General information

NPI: 1982708368
Provider Name (Legal Business Name): JACK W MILLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL PL STE 104
CARROLLTON GA
30117-3874
US

IV. Provider business mailing address

100 PROFESSIONAL PL STE 104
CARROLLTON GA
30117-3874
US

V. Phone/Fax

Practice location:
  • Phone: 770-830-7039
  • Fax: 770-830-7149
Mailing address:
  • Phone: 770-830-7039
  • Fax: 770-830-7149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number044541
License Number StateGA

VIII. Authorized Official

Name: DR. JACK W MILLER
Title or Position: PHYSICIAN
Credential: MD
Phone: 770-830-7039