1700881133 NPI number — MRS. JENNIFER MARIE FABRE FAIRLEY P.T. PH.D. CSCS

Table of content: MRS. JENNIFER MARIE FABRE FAIRLEY P.T. PH.D. CSCS (NPI 1700881133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700881133 NPI number — MRS. JENNIFER MARIE FABRE FAIRLEY P.T. PH.D. CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FABRE FAIRLEY
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T. PH.D. CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FABRE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T., PH.D, CSCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700881133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 HIGHWAY 190 STE 26
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANDEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70448-3495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-778-2282
Provider Business Mailing Address Fax Number:
866-767-8329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 HIGHWAY 190 STE 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANDEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70448-3495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-778-2282
Provider Business Practice Location Address Fax Number:
866-767-8329
Provider Enumeration Date:
06/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  04964 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 4135 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)