Provider Demographics
NPI:1124492863
Name:LOGAN, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 MICHAEL ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9442
Mailing Address - Country:US
Mailing Address - Phone:208-901-2891
Mailing Address - Fax:208-365-4205
Practice Address - Street 1:1522 MICHAEL ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9442
Practice Address - Country:US
Practice Address - Phone:208-901-2891
Practice Address - Fax:208-365-4205
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator