Healthcare Provider Details

I. General information

NPI: 1295519528
Provider Name (Legal Business Name): JEANETTE LEAH MILLER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E POWELL BLVD STE 303
GRESHAM OR
97030-7620
US

IV. Provider business mailing address

1540 NE 205TH AVE
FAIRVIEW OR
97024-9709
US

V. Phone/Fax

Practice location:
  • Phone: 503-218-3624
  • Fax:
Mailing address:
  • Phone: 530-210-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR8494
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: