Provider Demographics
NPI:1427051671
Name:LOGAN, JENNIFER P (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6715 ANTIGUA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9433
Mailing Address - Country:US
Mailing Address - Phone:970-372-0696
Mailing Address - Fax:970-372-0696
Practice Address - Street 1:6715 ANTIGUA DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9433
Practice Address - Country:US
Practice Address - Phone:970-372-0696
Practice Address - Fax:970-372-0696
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50382207W00000X
NY198357207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01787306Medicaid
NY082X1110Medicare ID - Type Unspecified
NY01787306Medicaid