Provider Demographics
NPI:1548072069
Name:MILLER, KENNETH JOSEPH JR (LMFT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 EAGLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8394
Mailing Address - Country:US
Mailing Address - Phone:904-710-9295
Mailing Address - Fax:
Practice Address - Street 1:1532 KINGSLEY AVE STE 112-114
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4538
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT5119106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist