MEDICARE: DR. JENNIFER MILLER-GREEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	789	SC

General Provider Information

NPI Number	:	1083958854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MILLER-GREEN PH.D.

Provider Business Mailing Address
First Line	:	1721 SHIVERS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-5413
Country	:	US
Telephone Number	:	803-896-7450
Fax Number	:	803-896-7451

Provider Business Practice Location Address
First Line	:	1721 SHIVERS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-5413
Country	:	US
Telephone Number	:	803-896-7450
Fax Number	:	803-896-7451

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	11/19/2012

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