Provider Demographics
NPI:1407530397
Name:LOGAN, JAMES JR
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LOGAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1660 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2048
Practice Address - Country:US
Practice Address - Phone:662-258-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1700894730OtherMENTAL HEALTH COUNSELOR