Provider Demographics
NPI:1649466541
Name:MILLER, JADA (EDS)
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S 114TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-9184
Mailing Address - Country:US
Mailing Address - Phone:623-703-2834
Mailing Address - Fax:623-478-1863
Practice Address - Street 1:2122 S 114TH LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-9184
Practice Address - Country:US
Practice Address - Phone:623-703-2834
Practice Address - Fax:623-478-1863
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3924598174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3924598OtherSTATE CERTIFICATION