Healthcare Provider Details

I. General information

NPI: 1285373852
Provider Name (Legal Business Name): JENNIFER PAULETTE MILES-BROWN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6781 LONDONDERRY WAY UNIT 4A
UNION CITY GA
30291-2094
US

IV. Provider business mailing address

109 SCARBRUSH CT
STOCKBRIDGE GA
30281-1017
US

V. Phone/Fax

Practice location:
  • Phone: 404-465-1555
  • Fax:
Mailing address:
  • Phone: 510-932-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: