Provider Demographics
NPI:1558129429
Name:FAIRCLOTH, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 GENESIS DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-0595
Mailing Address - Country:US
Mailing Address - Phone:478-697-5881
Mailing Address - Fax:
Practice Address - Street 1:1711 GENESIS DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-0595
Practice Address - Country:US
Practice Address - Phone:478-246-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion