Provider Demographics
NPI:1023200581
Name:LOGAN, JAMILAH Q (PHD)
Entity Type:Individual
Prefix:
First Name:JAMILAH
Middle Name:Q
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 W MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-5065
Mailing Address - Country:US
Mailing Address - Phone:850-528-8525
Mailing Address - Fax:
Practice Address - Street 1:9261 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2941
Practice Address - Country:US
Practice Address - Phone:623-533-3901
Practice Address - Fax:623-533-3902
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool