Provider Demographics
NPI:1669619482
Name:MILLER, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:UTOFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:644 EDEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-6031
Mailing Address - Country:US
Mailing Address - Phone:866-351-5875
Mailing Address - Fax:
Practice Address - Street 1:644 EDEN PARK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-6031
Practice Address - Country:US
Practice Address - Phone:866-351-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004204363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH004204OtherLICENSE