Provider Demographics
NPI:1013574789
Name:LOGSDON, JEREMY D (CNP- FAMILY)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:D
Last Name:LOGSDON
Suffix:
Gender:M
Credentials:CNP- FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 CHOCTAW ST
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-1626
Mailing Address - Country:US
Mailing Address - Phone:580-327-1118
Mailing Address - Fax:580-327-3067
Practice Address - Street 1:604 CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-1626
Practice Address - Country:US
Practice Address - Phone:580-327-1118
Practice Address - Fax:580-327-3067
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK86008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily