Provider Demographics
NPI:1558749796
Name:LOGOTHETIS, JILL (APRN, CPNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LOGOTHETIS
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8616
Mailing Address - Country:US
Mailing Address - Phone:850-474-4777
Mailing Address - Fax:
Practice Address - Street 1:1530 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8616
Practice Address - Country:US
Practice Address - Phone:850-474-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881494363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics