Healthcare Provider Details

I. General information

NPI: 1376608760
Provider Name (Legal Business Name): JESSA SUSAN MILLER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSA SUSAN HODGE PT

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 OCONNOR ST
WELLSVILLE NY
14895-1055
US

IV. Provider business mailing address

PO BOX 41 3931 COTTAGE BRIDGE RD
SCIO NY
14880
US

V. Phone/Fax

Practice location:
  • Phone: 585-593-5700
  • Fax: 585-593-4529
Mailing address:
  • Phone: 585-593-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0215191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: