Provider Demographics
NPI:1902426232
Name:MILLER-KHODIK, JESSE D (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:D
Last Name:MILLER-KHODIK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:JESSE
Other - Middle Name:D
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:62 NEWTON TER
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1919
Mailing Address - Country:US
Mailing Address - Phone:860-961-1354
Mailing Address - Fax:
Practice Address - Street 1:62 NEWTON TER
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1919
Practice Address - Country:US
Practice Address - Phone:860-961-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4392101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty