Provider Demographics
NPI:1588982904
Name:LOGAN, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:514 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3036
Mailing Address - Country:US
Mailing Address - Phone:310-937-8555
Mailing Address - Fax:310-937-8556
Practice Address - Street 1:514 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3036
Practice Address - Country:US
Practice Address - Phone:310-937-8555
Practice Address - Fax:310-937-8556
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine