Provider Demographics
NPI:1710759477
Name:LOGAN, JASEMINE LAFAYE
Entity Type:Individual
Prefix:
First Name:JASEMINE
Middle Name:LAFAYE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 OLD CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2401
Mailing Address - Country:US
Mailing Address - Phone:952-854-1800
Mailing Address - Fax:952-854-5502
Practice Address - Street 1:9201 OLD CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2401
Practice Address - Country:US
Practice Address - Phone:952-854-1800
Practice Address - Fax:952-854-5502
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician