Provider Demographics
NPI:1376022079
Name:HAZAN, JACK (LMHC , CSAT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HAZAN
Suffix:
Gender:M
Credentials:LMHC , CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W 25TH ST APT 13C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6575
Mailing Address - Country:US
Mailing Address - Phone:917-453-9306
Mailing Address - Fax:
Practice Address - Street 1:1504 BAY RD APT 2003
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-3277
Practice Address - Country:US
Practice Address - Phone:917-453-9306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
NY01078301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty