Provider Demographics
NPI:1316587520
Name:LOGAN, JALINIA (LCSW)
Entity Type:Individual
Prefix:
First Name:JALINIA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4579
Mailing Address - Country:US
Mailing Address - Phone:773-544-3951
Mailing Address - Fax:
Practice Address - Street 1:9435 BORMET DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8363
Practice Address - Country:US
Practice Address - Phone:708-995-7226
Practice Address - Fax:708-995-7227
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 174H00000X
IL043105752164W00000X
IL1490219721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL27-4113346OtherGREAT CHANGES COUNSELING SERVICES