Provider Demographics
NPI:1144597626
Name:LOGAN, JENNA KALEEN (ASW, SUDCC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:KALEEN
Last Name:LOGAN
Suffix:
Gender:F
Credentials:ASW, SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 ARROW CT
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4226
Mailing Address - Country:US
Mailing Address - Phone:619-870-5456
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3889
Practice Address - Country:US
Practice Address - Phone:619-398-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
CA98936101YA0400X
CA6079101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health