Provider Demographics
NPI:1548423973
Name:LOGIUDICE, JENNA A (LNM)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:A
Last Name:LOGIUDICE
Suffix:
Gender:F
Credentials:LNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-754-2535
Mailing Address - Fax:203-754-0788
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-754-2535
Practice Address - Fax:203-754-0788
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000319207V00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000319OtherCT NURSE MIDWIFE LICENSE