Healthcare Provider Details

I. General information

NPI: 1114301579
Provider Name (Legal Business Name): JACKLYN ANNE MILLER AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12775 ESCANABA DR
DEWITT MI
48820-8615
US

IV. Provider business mailing address

12775 ESCANABA DR
DEWITT MI
48820-8615
US

V. Phone/Fax

Practice location:
  • Phone: 517-669-8080
  • Fax: 517-669-8070
Mailing address:
  • Phone: 517-669-8080
  • Fax: 517-669-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000710
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: