Provider Demographics
NPI:1104824341
Name:FAIRCHILD, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SCHOOL ST
Mailing Address - Street 2:JASPER SCHOOL DISTRICT
Mailing Address - City:JASPER
Mailing Address - State:AR
Mailing Address - Zip Code:72641-8802
Mailing Address - Country:US
Mailing Address - Phone:870-446-9305
Mailing Address - Fax:870-446-6754
Practice Address - Street 1:600 SCHOOL ST
Practice Address - Street 2:JASPER SCHOOL DISTRICT
Practice Address - City:JASPER
Practice Address - State:AR
Practice Address - Zip Code:72641-8802
Practice Address - Country:US
Practice Address - Phone:870-446-9305
Practice Address - Fax:870-446-6754
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002031917101YP2500X
ARP1011074101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497205401Medicaid