Provider Demographics
NPI:1154991131
Name:FAIRBANKS, JILL MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:1564 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3849
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:618-542-8792
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty