Healthcare Provider Details

I. General information

NPI: 1790089563
Provider Name (Legal Business Name): JENNIFER MICHELLE MIRON B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 KRESGE LN
SPARKS NV
89431-6435
US

IV. Provider business mailing address

350 KRESGE LN
SPARKS NV
89431-6435
US

V. Phone/Fax

Practice location:
  • Phone: 775-359-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: