Healthcare Provider Details

I. General information

NPI: 1053353045
Provider Name (Legal Business Name): JACKIE S MILLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 E US HIGHWAY 136
ALBANY MO
64402-8223
US

IV. Provider business mailing address

1607 E US HIGHWAY 136
ALBANY MO
64402-8223
US

V. Phone/Fax

Practice location:
  • Phone: 660-726-3311
  • Fax:
Mailing address:
  • Phone: 660-726-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number104860
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: