Provider Demographics
NPI:1538930235
Name:JAY, HAZEL
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:JAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6714 HIGHWAY 85 # A
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2383
Mailing Address - Country:US
Mailing Address - Phone:510-415-2089
Mailing Address - Fax:
Practice Address - Street 1:6714 HIGHWAY 85 # A
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2383
Practice Address - Country:US
Practice Address - Phone:510-415-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist