Healthcare Provider Details

I. General information

NPI: 1497345359
Provider Name (Legal Business Name): JESSICA T MILLER DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N MAIN ST STE 304
CROWN POINT IN
46307-1877
US

IV. Provider business mailing address

PO BOX 10299
FORT WAYNE IN
46851-0299
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax: 574-546-1999
Mailing address:
  • Phone: 574-546-1900
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704377817
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016536
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71010828A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: