Healthcare Provider Details

I. General information

NPI: 1104824341
Provider Name (Legal Business Name): NICOLE FAIRCHILD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SCHOOL ST JASPER SCHOOL DISTRICT
JASPER AR
72641-8802
US

IV. Provider business mailing address

600 SCHOOL ST JASPER SCHOOL DISTRICT
JASPER AR
72641-8802
US

V. Phone/Fax

Practice location:
  • Phone: 870-446-9305
  • Fax: 870-446-6754
Mailing address:
  • Phone: 870-446-9305
  • Fax: 870-446-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2002031917
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberP1011074
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: