Provider Demographics
NPI:1871940049
Name:MILLER, JESIKA MOXLEY
Entity type:Individual
Prefix:
First Name:JESIKA
Middle Name:MOXLEY
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESIKA
Other - Middle Name:LEN
Other - Last Name:MOXLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 S 19TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2961
Mailing Address - Country:US
Mailing Address - Phone:253-312-3598
Mailing Address - Fax:
Practice Address - Street 1:9307 N LAKE DR SW STE 110
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-1135
Practice Address - Country:US
Practice Address - Phone:253-370-8173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid