Provider Demographics
NPI:1093314148
Name:HAZEL, JODY LEE (LMT)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:HAZEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E COLBORN CAMP LN
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:IL
Mailing Address - Zip Code:62868-2348
Mailing Address - Country:US
Mailing Address - Phone:618-302-1703
Mailing Address - Fax:
Practice Address - Street 1:1750 E COLBORN CAMP LN
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:IL
Practice Address - Zip Code:62868-2348
Practice Address - Country:US
Practice Address - Phone:618-302-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.008542225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty