Healthcare Provider Details

I. General information

NPI: 1265869903
Provider Name (Legal Business Name): JESSICA CODY MILLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA CODY FRICK

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 EVERSMAN DRIVE
JASPER IN
47547-0769
US

IV. Provider business mailing address

800 W 9TH ST
JASPER IN
47546-2516
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-3020
  • Fax: 812-482-6409
Mailing address:
  • Phone: 812-996-8313
  • Fax: 812-996-5784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number99058554A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007960A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: