Healthcare Provider Details

I. General information

NPI: 1194208314
Provider Name (Legal Business Name): JENNIFER MILLER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 REVOLUTION DR
SOMERVILLE MA
02145-1484
US

IV. Provider business mailing address

78 MACARTHUR RD
NATICK MA
01760-2938
US

V. Phone/Fax

Practice location:
  • Phone: 857-523-2233
  • Fax:
Mailing address:
  • Phone: 617-721-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113746
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: