Provider Demographics
NPI:1376821892
Name:FAIRMAN PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:FAIRMAN PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:FAIRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-437-3244
Mailing Address - Street 1:2722 S. MAIN ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-437-3244
Mailing Address - Fax:
Practice Address - Street 1:2722 S. MAIN ST.
Practice Address - Street 2:SUITE A
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-437-3244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004033756103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty