Provider Demographics
NPI:1144726019
Name:HAZEN, JESSICA ANN (MS, RD, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:HAZEN
Suffix:
Gender:F
Credentials:MS, RD, IBCLC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:SOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, IBCLC
Mailing Address - Street 1:2502 E 4TH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2502 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3965
Practice Address - Country:US
Practice Address - Phone:360-397-8459
Practice Address - Fax:360-397-4367
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10190313133V00000X, 133VN1004X, 174N00000X
174N00000X
WADI60841895133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No174N00000XOther Service ProvidersLactation Consultant, Non-RN