MEDICARE: JESSICA LAUREN LEIGH MILLER

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

General Provider Information

NPI Number	:	1629801386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LAUREN LEIGH MILLER

Provider Business Mailing Address
First Line	:	4201 HENRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-5409
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 S COLORADO ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-4733
Country	:	US
Telephone Number	:	609-442-1763
Fax Number	:

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

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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