Provider Demographics
NPI:1699547562
Name:LOGAN, JATWAN DAKARR
Entity type:Individual
Prefix:
First Name:JATWAN
Middle Name:DAKARR
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-2110
Mailing Address - Country:US
Mailing Address - Phone:234-281-5672
Mailing Address - Fax:
Practice Address - Street 1:1463 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44301-2110
Practice Address - Country:US
Practice Address - Phone:234-281-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver