Provider Demographics
NPI:1497386627
Name:HAZELRIG, JORDYN R (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:R
Last Name:HAZELRIG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:R
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:4640 MARTIN ROAD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5571
Mailing Address - Country:US
Mailing Address - Phone:678-679-1261
Mailing Address - Fax:678-250-9010
Practice Address - Street 1:4640 MARTIN ROAD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5571
Practice Address - Country:US
Practice Address - Phone:678-679-1261
Practice Address - Fax:678-250-9010
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003230074AMedicaid