Provider Demographics
NPI:1336473149
Name:SIAMU, JACK S (MS LPC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:S
Last Name:SIAMU
Suffix:
Gender:M
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 CENTRAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-2036
Mailing Address - Country:US
Mailing Address - Phone:505-352-3441
Mailing Address - Fax:505-352-3400
Practice Address - Street 1:6301 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-2036
Practice Address - Country:US
Practice Address - Phone:505-352-3441
Practice Address - Fax:505-352-3400
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health