Provider Demographics
NPI:1497115216
Name:LOGUE, JACKLYN (CNP)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:LOGUE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 FOX RUN PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5370
Mailing Address - Country:US
Mailing Address - Phone:605-665-0062
Mailing Address - Fax:
Practice Address - Street 1:2525 FOX RUN PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-5370
Practice Address - Country:US
Practice Address - Phone:605-665-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001028363L00000X
NE111973363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner