Provider Demographics
NPI:1255499570
Name:LOGAN, JESSICA LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 CASTLE POINT TER
Mailing Address - Street 2:APT. #2
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5908
Mailing Address - Country:US
Mailing Address - Phone:201-618-0623
Mailing Address - Fax:
Practice Address - Street 1:11 KIEL AVE
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2549
Practice Address - Country:US
Practice Address - Phone:973-838-4460
Practice Address - Fax:973-838-6258
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02262300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist