Provider Demographics
NPI:1659489391
Name:FAIRBANK, JENNIFER A (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4270 MINTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9578
Mailing Address - Country:US
Mailing Address - Phone:321-984-2933
Mailing Address - Fax:321-953-5379
Practice Address - Street 1:4270 MINTON RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-984-2933
Practice Address - Fax:321-953-5379
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT14435OtherPT LICENSE