Healthcare Provider Details

I. General information

NPI: 1871847871
Provider Name (Legal Business Name): JAY A. MILLER MA, LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CLAYSTONE ST SE
GRAND RAPIDS MI
49546-7716
US

IV. Provider business mailing address

PO BOX 30516 DEPT 6065
LANSING MI
48909-8016
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-7460
  • Fax: 616-949-3018
Mailing address:
  • Phone: 800-968-6866
  • Fax: 616-532-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: