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General NPI Number Information
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NPI Number | 1265864359
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Entity Type | Individual
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Provider Name | BRET LEE JACOBSEN MILLER PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/31/2013
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Last Update Date | 03/19/2021
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Provider Practice Location Address
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Address Line | 11034 N 23RD DR STE 105B
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City | PHOENIX
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State | AZ
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Zip | 85029-4743
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Country | US
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Telephone | 602-639-0189
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Fax | 844-955-2502
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Provider Business Mailing Address
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Address Line | 3637 W ECHO LN
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City | PHOENIX
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State | AZ
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Zip | 85051-4753
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Country | US
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Telephone | 602-317-6644
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5445
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License Number State | AZ
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