Provider Demographics
NPI:1912014184
Name:FAIRCHILD, JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11709 OLD BALLAS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7029
Mailing Address - Country:US
Mailing Address - Phone:314-993-1200
Mailing Address - Fax:314-993-1240
Practice Address - Street 1:11709 OLD BALLAS RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-993-1200
Practice Address - Fax:314-993-1240
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007022721207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207463902Medicaid