Healthcare Provider Details

I. General information

NPI: 1053989699
Provider Name (Legal Business Name): JANINE HAZEL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR
APO AA
29154-5024
US

IV. Provider business mailing address

420 POLIFKA DR
APO AA
29154-5024
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6199
  • Fax:
Mailing address:
  • Phone: 803-895-6199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810009265
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: