Healthcare Provider Details

I. General information

NPI: 1093296865
Provider Name (Legal Business Name): MS. JESSICA MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/05/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 E 70TH ST STE 301
SHREVEPORT LA
71105-5332
US

IV. Provider business mailing address

1520 LEXINGTON DR
BOSSIER CITY LA
71111-2086
US

V. Phone/Fax

Practice location:
  • Phone: 318-553-5591
  • Fax: 318-553-5592
Mailing address:
  • Phone: 318-401-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: