Provider Demographics
NPI:1255453437
Name:HAZEL, SUSAN JILL (PMHNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JILL
Last Name:HAZEL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13510
Mailing Address - Street 2:MHPBS
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-249-0181
Mailing Address - Fax:
Practice Address - Street 1:15100 BOONES FERRY RD
Practice Address - Street 2:#700
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3469
Practice Address - Country:US
Practice Address - Phone:503-330-5092
Practice Address - Fax:503-892-3129
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000036739N6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health