Provider Demographics
NPI:1073280335
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 1:2479 PEACHTREE RD NE APT 308
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-4129
Mailing Address - Country:US
Mailing Address - Phone:404-308-0191
Mailing Address - Fax:
Practice Address - Street 1:2479 PEACHTREE RD NE APT 308
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-4129
Practice Address - Country:US
Practice Address - Phone:404-308-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor