Healthcare Provider Details

I. General information

NPI: 1083656979
Provider Name (Legal Business Name): JENNIFER E MILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 MAPLE AVE STE 100
EVANSTON IL
60201-3134
US

IV. Provider business mailing address

680 N LAKE SHORE DR STE 1000
CHICAGO IL
60611-8709
US

V. Phone/Fax

Practice location:
  • Phone: 312-694-2273
  • Fax: 312-694-2299
Mailing address:
  • Phone: 312-695-0665
  • Fax: 312-695-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002629
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: