Provider Demographics
NPI:1326192014
Name:LOGAN, JAY F (LSCSW)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:F
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-0677
Mailing Address - Country:US
Mailing Address - Phone:785-242-3780
Mailing Address - Fax:785-242-6397
Practice Address - Street 1:2537 EISENHOWER RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-9482
Practice Address - Country:US
Practice Address - Phone:785-242-3780
Practice Address - Fax:785-242-6397
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 22851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200431410AMedicaid
KSP70571Medicare UPIN
KS069688Medicare ID - Type UnspecifiedMEDICARE