Provider Demographics
NPI:1184043903
Name:LOGAN, JENNIFER KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KRISTIN
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 1:1400 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2134
Mailing Address - Country:US
Mailing Address - Phone:321-841-8650
Mailing Address - Fax:321-841-3794
Practice Address - Street 1:1400 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:321-841-8650
Practice Address - Fax:321-841-3794
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1403822085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102640400Medicaid