Provider Demographics
NPI:1902968845
Name:MCMILLIAN, JENNIE ELISE (LPC, MA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:ELISE
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:ELISE
Other - Last Name:WEITEKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:489 N ARROYO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2644
Mailing Address - Country:US
Mailing Address - Phone:520-287-4713
Mailing Address - Fax:520-287-9794
Practice Address - Street 1:590 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6405
Practice Address - Country:US
Practice Address - Phone:520-586-7080
Practice Address - Fax:520-586-3163
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 12138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083315OtherAHCCCS