Healthcare Provider Details

I. General information

NPI: 1174551774
Provider Name (Legal Business Name): JEANINE S FAIR MSW, CICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 HUNTERS TRL
PORTAGE WI
53901-3403
US

IV. Provider business mailing address

2901 HUNTERS TRL PO BOX 301
PORTAGE WI
53901-3403
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-5518
  • Fax: 608-742-4087
Mailing address:
  • Phone: 608-742-5518
  • Fax: 608-742-4087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3127-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: