Provider Demographics
NPI:1710759139
Name:LOGAN, JESSICA LEANNE (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANNE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SHAMROCK HL
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-6317
Mailing Address - Country:US
Mailing Address - Phone:606-316-0437
Mailing Address - Fax:
Practice Address - Street 1:505 PRISON CONNECTOR
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:KY
Practice Address - Zip Code:41171-7010
Practice Address - Country:US
Practice Address - Phone:606-738-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4007909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner