Healthcare Provider Details

I. General information

NPI: 1386081065
Provider Name (Legal Business Name): JENNIFER LYNN FAIRBANKS O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201
US

IV. Provider business mailing address

1801 19TH AVE SW
WILLMAR MN
56201
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2020
  • Fax:
Mailing address:
  • Phone: 320-235-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3334
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: