Healthcare Provider Details

I. General information

NPI: 1619801131
Provider Name (Legal Business Name): JACOB ALLEN MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25595 COOLIDGE HWY
OAK PARK MI
48237-1306
US

IV. Provider business mailing address

46455 JONATHAN CIR APT 207
SHELBY TOWNSHIP MI
48317-3872
US

V. Phone/Fax

Practice location:
  • Phone: 248-677-3126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152001454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: