Healthcare Provider Details

I. General information

NPI: 1124535489
Provider Name (Legal Business Name): KATELYNN RENEE MILLER MA, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
JACKSON MI
49202-2179
US

IV. Provider business mailing address

2453 SHIRLEY DR
JACKSON MI
49202-1523
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1209
  • Fax:
Mailing address:
  • Phone: 517-215-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401019111
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: