Provider Demographics
NPI:1700881133
Name:FABRE FAIRLEY, JENNIFER MARIE (PT PHD CSCS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:FABRE FAIRLEY
Suffix:
Gender:F
Credentials:PT PHD CSCS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:FABRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, PHD, CSCS
Mailing Address - Street 1:1901 HIGHWAY 190 STE 26
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3495
Mailing Address - Country:US
Mailing Address - Phone:985-778-2282
Mailing Address - Fax:866-767-8329
Practice Address - Street 1:1901 HIGHWAY 190 STE 26
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3495
Practice Address - Country:US
Practice Address - Phone:985-778-2282
Practice Address - Fax:866-767-8329
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04964225100000X
NM4135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C914Medicare UPIN