Provider Demographics
NPI:1932128436
Name:LOGAN, JEFFERY A (LAC,LLC)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LAC,LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 AUBURN ST
Mailing Address - Street 2:STE 103
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6004
Mailing Address - Country:US
Mailing Address - Phone:207-780-8880
Mailing Address - Fax:207-773-0959
Practice Address - Street 1:222 AUBURN ST
Practice Address - Street 2:STE 103
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6004
Practice Address - Country:US
Practice Address - Phone:207-780-8880
Practice Address - Fax:207-773-0959
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC157171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME036445OtherBC/BS STAR
MEM23908OtherCIGNA-NH
ME1815546OtherCIGNA
ME2425756OtherAETNA