Basic Information
| Provider Information | |||||||||
| NPI: | 1063832830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRCHILD | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.C., N.C.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5737 HARTNECK RD | ||||||||
| Address2: | |||||||||
| City: | VALLEY CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442809767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047638083 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608453 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 04/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C1400045 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.