Provider Demographics
NPI:1588662787
Name:SEGELEON, JENNIFER LOGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LOGAN
Last Name:SEGELEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:100 MALLARD CREEK RD STE 395
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5167
Practice Address - Country:US
Practice Address - Phone:502-895-9421
Practice Address - Fax:502-899-5762
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY37791208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY138722OtherSIHO - KCMA
KY7100133960Medicaid
KY50039818OtherPASSPORT - KCMA
KY000000777755OtherANTHEM - KCMA