Provider Demographics
NPI:1801939426
Name:MILLER JACOBUS, KATIE M
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:MILLER JACOBUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POBOX 1094
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631
Mailing Address - Country:US
Mailing Address - Phone:508-237-6642
Mailing Address - Fax:
Practice Address - Street 1:1070 ROUTE 134
Practice Address - Street 2:
Practice Address - City:EAST DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02641
Practice Address - Country:US
Practice Address - Phone:508-385-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2133131041C0700X
MA1151951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical