Provider Demographics
NPI:1538145008
Name:LOGAN, JENNIFER C (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-291-6554
Mailing Address - Fax:860-528-0778
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-246-6589
Practice Address - Fax:860-560-2849
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0433582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA2516306OtherOXFORD
CT001433581Medicaid
CT010043358CT01OtherANTHEM BC/BS
CT300003626Medicare ID - Type Unspecified
CT001433581Medicaid