Provider Demographics
NPI:1124645981
Name:LOGUE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOGUE
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 1:791 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2045
Mailing Address - Country:US
Mailing Address - Phone:478-755-8838
Mailing Address - Fax:
Practice Address - Street 1:791 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2045
Practice Address - Country:US
Practice Address - Phone:478-755-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-28
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258772163WM0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn