Provider Demographics
NPI:1578871836
Name:LOGAN, JENNIFER JOY (COTA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:JOY
Last Name:LOGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 LIOBA DR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9764
Mailing Address - Country:US
Mailing Address - Phone:316-259-0765
Mailing Address - Fax:
Practice Address - Street 1:6700 E 45TH ST N
Practice Address - Street 2:
Practice Address - City:BEL AIRE
Practice Address - State:KS
Practice Address - Zip Code:67226-8817
Practice Address - Country:US
Practice Address - Phone:316-744-4109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00737224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant