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: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH PKWY STE 202
WORCESTER MA
01605-1349
US

IV. Provider business mailing address

73 MOUNT WAYTE AVE
FRAMINGHAM MA
01702-5803
US

V. Phone/Fax

Practice location:
  • Phone: 857-289-9082
  • Fax:
Mailing address:
  • Phone: 857-289-9082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: