Basic Information
| Provider Information | |||||||||
| NPI: | 1164598892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IBSEN | ||||||||
| OtherFirstName: | JAKE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 PARMAC RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959262294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308793950 | ||||||||
| FaxNumber: | 5308793949 | ||||||||
| Practice Location | |||||||||
| Address1: | 564 RIO LINDO AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959261852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308793950 | ||||||||
| FaxNumber: | 5308793949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.