Provider Demographics
NPI:1174229728
Name:MILLER, JENNA BETHANY (MS, AT, ATC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:BETHANY
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7171 TIMBER RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7668
Mailing Address - Country:US
Mailing Address - Phone:734-634-0251
Mailing Address - Fax:
Practice Address - Street 1:500 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1382
Practice Address - Country:US
Practice Address - Phone:734-936-2938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2000052768OtherBOARD OF CERTIFICATION