Provider Demographics
NPI:1417559287
Name:HAZLY, JIBREEL N
Entity type:Individual
Prefix:
First Name:JIBREEL
Middle Name:N
Last Name:HAZLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1959
Mailing Address - Country:US
Mailing Address - Phone:330-618-5246
Mailing Address - Fax:
Practice Address - Street 1:1225 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1959
Practice Address - Country:US
Practice Address - Phone:330-618-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TM1800X, 106S00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251E00000XAgenciesHome Health