Provider Demographics
NPI:1386978682
Name:LOGSDON, JACOB T (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:T
Last Name:LOGSDON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3071
Mailing Address - Country:US
Mailing Address - Phone:308-289-4981
Mailing Address - Fax:
Practice Address - Street 1:1987 S 8TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3071
Practice Address - Country:US
Practice Address - Phone:308-289-4981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1467363AM0700X
FLPA9106688363AM0700X
GA6435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical