Healthcare Provider Details

I. General information

NPI: 1255051298
Provider Name (Legal Business Name): JANICE LYNN FAIRBANK LPC, LIAC, SAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E PLAZA DR
EAGLE ID
83616-6566
US

IV. Provider business mailing address

6317 WEST AVILLA STREET , MERIDIAN, ID
MERIDIAN ID
83646
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-2836
  • Fax:
Mailing address:
  • Phone: 602-488-7417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-15597
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-8471063
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-23937
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: