Provider Demographics
NPI:1194331041
Name:SIRICHANTHO, JACKKY (MA)
Entity type:Individual
Prefix:
First Name:JACKKY
Middle Name:
Last Name:SIRICHANTHO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 S LOCUST ST STE 216
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-7132
Mailing Address - Country:US
Mailing Address - Phone:720-213-8378
Mailing Address - Fax:
Practice Address - Street 1:2755 S LOCUST ST STE 216
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-7132
Practice Address - Country:US
Practice Address - Phone:720-213-8378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14905101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14905Other14905