Provider Demographics
NPI:1730489725
Name:FAIRCHILD, JEFFREY R (ACADC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:R
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N INGLEWOOD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-3735
Mailing Address - Country:US
Mailing Address - Phone:424-227-2289
Mailing Address - Fax:
Practice Address - Street 1:4715 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1233
Practice Address - Country:US
Practice Address - Phone:323-988-3744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)