Healthcare Provider Details

I. General information

NPI: 1083190581
Provider Name (Legal Business Name): JESSICA FAIRBAIRN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W HUNT HWY # B103
SAN TAN VLY AZ
85143-5215
US

IV. Provider business mailing address

4259 E OAKLAND ST
GILBERT AZ
85295-6120
US

V. Phone/Fax

Practice location:
  • Phone: 480-568-4580
  • Fax:
Mailing address:
  • Phone: 815-690-7913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30100
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: