Healthcare Provider Details

I. General information

NPI: 1023512902
Provider Name (Legal Business Name): JENNIFER LYNN MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 02/25/2022
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

V. Phone/Fax

Practice location:
  • Phone: 216-320-6447
  • Fax: 216-320-8951
Mailing address:
  • Phone: 216-320-6447
  • Fax: 216-320-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: