Provider Demographics
NPI:1861971202
Name:HANSON, KAJZOO GRACE
Entity type:Individual
Prefix:
First Name:KAJZOO
Middle Name:GRACE
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3515 S ORCHARD ST APT E12
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6785
Mailing Address - Country:US
Mailing Address - Phone:612-845-9302
Mailing Address - Fax:
Practice Address - Street 1:3515 S ORCHARD ST APT E12
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98466-6785
Practice Address - Country:US
Practice Address - Phone:612-845-9302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60883859106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician