Provider Demographics
NPI:1841585163
Name:NIECKO, IAN
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:NIECKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEALASKA PLZ STE 303
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1245
Mailing Address - Country:US
Mailing Address - Phone:907-790-7272
Mailing Address - Fax:
Practice Address - Street 1:1 SEALASKA PLZ STE 303
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1245
Practice Address - Country:US
Practice Address - Phone:907-790-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK130024103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid