Healthcare Provider Details

I. General information

NPI: 1992790117
Provider Name (Legal Business Name): JONATHAN M MILLER PHD LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 CLIFF DR
EAGAN MN
55122-3327
US

IV. Provider business mailing address

2113 CLIFF DR
EAGAN MN
55122-3327
US

V. Phone/Fax

Practice location:
  • Phone: 651-728-0922
  • Fax:
Mailing address:
  • Phone: 651-728-0922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP4000
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: