Provider Demographics
NPI:1386144541
Name:LOGAN, JENNIFER-ANNE ROSE (LMT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER-ANNE
Middle Name:ROSE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-1238
Mailing Address - Country:US
Mailing Address - Phone:541-539-6371
Mailing Address - Fax:
Practice Address - Street 1:204 W 9TH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3135
Practice Address - Country:US
Practice Address - Phone:541-539-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21551225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist