Provider Demographics
NPI:1073689493
Name:CAMILLERI, JACK E (EDD,LPC & LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:CAMILLERI
Suffix:
Gender:M
Credentials:EDD,LPC & LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3116
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-3116
Mailing Address - Country:US
Mailing Address - Phone:251-625-1480
Mailing Address - Fax:251-625-1482
Practice Address - Street 1:28311 N MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7074
Practice Address - Country:US
Practice Address - Phone:251-625-1480
Practice Address - Fax:251-625-1482
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL626101YM0800X
ALLMFT 154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist