Provider Demographics
NPI:1063832830
Name:FAIRCHILD, JACKLYN ANN (PC, NCC)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ANN
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:PC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5737 HARTNECK RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:OH
Mailing Address - Zip Code:44280-9767
Mailing Address - Country:US
Mailing Address - Phone:704-763-8083
Mailing Address - Fax:
Practice Address - Street 1:202 E BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2058
Practice Address - Country:US
Practice Address - Phone:440-260-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1400045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional