Provider Demographics
NPI:1891476321
Name:LOGAN, JASMINE ALYSE (MA)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ALYSE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JASMIN
Other - Middle Name:ALYSE
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 13D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program