Provider Demographics
NPI:1124370226
Name:LOGAN, JENNIFER D (PHD, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:D
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:D
Other - Last Name:BRIDGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 APPALOOSA CIR
Mailing Address - Street 2:
Mailing Address - City:GOODFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61742-9300
Mailing Address - Country:US
Mailing Address - Phone:309-360-2268
Mailing Address - Fax:
Practice Address - Street 1:103 APPALOOSA CIR
Practice Address - Street 2:
Practice Address - City:GOODFIELD
Practice Address - State:IL
Practice Address - Zip Code:61742-9300
Practice Address - Country:US
Practice Address - Phone:309-360-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006924101YP2500X
IL180012370101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional