Provider Demographics
NPI:1639620768
Name:LOGAN, JENNIFER L (RD, CDE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:HRUBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-525-6485
Mailing Address - Fax:707-573-6918
Practice Address - Street 1:1701 4TH ST STE 210
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3661
Practice Address - Country:US
Practice Address - Phone:707-578-7530
Practice Address - Fax:707-578-7533
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered