Provider Demographics
NPI:1265128797
Name:FAIRBANKS, AMANDA JANE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JANE
Other - Last Name:KERSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W YORKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3924
Mailing Address - Country:US
Mailing Address - Phone:801-616-6322
Mailing Address - Fax:
Practice Address - Street 1:384 E 60 S
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3835
Practice Address - Country:US
Practice Address - Phone:801-901-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist