Provider Demographics
NPI:1033562558
Name:LOGAN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2779 VOLUNTEER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-8618
Mailing Address - Country:US
Mailing Address - Phone:309-345-9400
Mailing Address - Fax:309-345-9401
Practice Address - Street 1:2779 VOLUNTEER DR STE 201
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-8618
Practice Address - Country:US
Practice Address - Phone:309-345-9400
Practice Address - Fax:309-345-9401
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10005502363L00000X
IL209-014448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner