Provider Demographics
NPI:1750047700
Name:FAIRBANKS, JACQUELINE (CCC MS/L)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:CCC MS/L
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC MS/L
Mailing Address - Street 1:22382 N RICHMOND CT
Mailing Address - Street 2:
Mailing Address - City:KILDEER
Mailing Address - State:IL
Mailing Address - Zip Code:60047-7948
Mailing Address - Country:US
Mailing Address - Phone:815-742-0890
Mailing Address - Fax:
Practice Address - Street 1:40 E DUNDEE RD
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-5227
Practice Address - Country:US
Practice Address - Phone:224-770-4339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist