Basic Information
| Provider Information | |||||||||
| NPI: | 1255051298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRBANK | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5250 N 20TH ST APT 117 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024887417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9610 N METRO PKWY W | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850511402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2022 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LASAC-15338 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.