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 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-457-3065
Practice Address - Fax:618-351-6476
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022604363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty