Provider Demographics
NPI:1972053973
Name:HAZEL, JESSE (LCSWA, LCASA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:HAZEL
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3424
Mailing Address - Country:US
Mailing Address - Phone:252-946-3666
Mailing Address - Fax:252-945-5499
Practice Address - Street 1:1308 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3424
Practice Address - Country:US
Practice Address - Phone:252-946-3666
Practice Address - Fax:252-945-5499
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22936101YA0400X
NCP0105701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)