Provider Demographics
NPI:1538426663
Name:MILLER, JESSICA LYNN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:LEATHERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7218
Mailing Address - Fax:307-739-7446
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-7218
Practice Address - Fax:307-739-7446
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY35590.1404367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered