Provider Demographics
NPI:1033209796
Name:HAZEN, JENNIE PATRICIA (LPC)
Entity type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:PATRICIA
Last Name:HAZEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4246 S SKYRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5186
Mailing Address - Country:US
Mailing Address - Phone:208-880-6900
Mailing Address - Fax:
Practice Address - Street 1:1111 S ORCHARD ST
Practice Address - Street 2:SUITE #171
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1966
Practice Address - Country:US
Practice Address - Phone:208-336-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3644101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional