Provider Demographics
NPI:1881031524
Name:FAIRBANKS, JARED JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:JAY
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16134 KILLDEER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-8628
Mailing Address - Country:US
Mailing Address - Phone:641-231-1679
Mailing Address - Fax:
Practice Address - Street 1:1605 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4234
Practice Address - Country:US
Practice Address - Phone:320-235-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist