Basic Information
| Provider Information | |||||||||
| NPI: | 1881031524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRBANKS | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16134 KILLDEER AVE | ||||||||
| Address2: | |||||||||
| City: | CLEAR LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504288628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6412311679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1605 1ST ST S | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202359060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3333 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.