Provider Demographics
NPI:1083841134
Name:LOGAN, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 IRVING ST NW
Mailing Address - Street 2:MEDICAL SERVICE OFFICE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20422-0001
Mailing Address - Country:US
Mailing Address - Phone:202-745-8000
Mailing Address - Fax:202-745-8184
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:MEDICAL SERVICE OFFICE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:202-745-8184
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD040514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program