Provider Demographics
NPI:1174934293
Name:MILES, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILES
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:DOLLAR BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49922-0645
Mailing Address - Country:US
Mailing Address - Phone:906-523-5619
Mailing Address - Fax:
Practice Address - Street 1:48567 THIRD ST
Practice Address - Street 2:
Practice Address - City:DOLLAR BAY
Practice Address - State:MI
Practice Address - Zip Code:49922-0645
Practice Address - Country:US
Practice Address - Phone:906-523-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008794225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist