Provider Demographics
NPI:1578212239
Name:MILLER, JENNIFER ROSE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 INNSLAKE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3344
Mailing Address - Country:US
Mailing Address - Phone:804-494-9760
Mailing Address - Fax:
Practice Address - Street 1:4112 INNSLAKE DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3344
Practice Address - Country:US
Practice Address - Phone:804-494-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health