MEDICARE: JIBREEL N HAZLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	103TM1800X	Intellectual & Developmental Disabilities Psychologist	OH
2	106S00000X	Behavior Technician	OH
3	251E00000X	Home Health Agency	OH

General Provider Information

NPI Number	:	1417559287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIBREEL N HAZLY

Provider Business Mailing Address
First Line	:	1225 N MAIN ST
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44720-1959
Country	:	US
Telephone Number	:	330-618-5246
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 N MAIN ST
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44720-1959
Country	:	US
Telephone Number	:	330-618-5246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	09/16/2025

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Directions to “ JIBREEL N HAZLY ” Practice Location

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