Provider Demographics
NPI:1508194945
Name:SIELAFF, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SIELAFF
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 1:210 E COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2514
Mailing Address - Country:US
Mailing Address - Phone:520-836-1688
Mailing Address - Fax:520-421-2708
Practice Address - Street 1:2271 S PEART RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-8545
Practice Address - Country:US
Practice Address - Phone:520-836-1713
Practice Address - Fax:520-836-4046
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10864101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10864OtherLISAC