Provider Demographics
NPI:1710257548
Name:LOGAN, JACQUELINE (LPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373119
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-3119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 E PONCE DE LEON AVE STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2512
Practice Address - Country:US
Practice Address - Phone:404-382-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006564101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional