Provider Demographics
NPI:1013945153
Name:LAIRD, JENNIFER LOGAN (DC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOGAN
Last Name:LAIRD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-0625
Mailing Address - Country:US
Mailing Address - Phone:850-835-9867
Mailing Address - Fax:850-880-6089
Practice Address - Street 1:40 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439-0625
Practice Address - Country:US
Practice Address - Phone:850-835-9867
Practice Address - Fax:850-880-6089
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8844111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76145OtherBCBS
FLV01071Medicare UPIN
FLU3007YMedicare PIN