MEDICARE: MS. JESSICA RAQUEL MILES ATC-L

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	2255A2300X	Athletic Trainer	927	AL
2	2255A2300X	Athletic Trainer	AT001878	GA

General Provider Information

NPI Number	:	1457561698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA RAQUEL MILES ATC-L

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 SHERWOOD PARK DRIVE, NE
Second Line	:	STE. 140
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3426
Country	:	US
Telephone Number	:	770-297-7750
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/11/2011

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