Provider Demographics
NPI:1356067227
Name:LOGAN, JALEA LANAE
Entity type:Individual
Prefix:
First Name:JALEA
Middle Name:LANAE
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 1:3503 SPRUCE CT
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1616
Mailing Address - Country:US
Mailing Address - Phone:760-509-5273
Mailing Address - Fax:
Practice Address - Street 1:3503 SPRUCE CT
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1616
Practice Address - Country:US
Practice Address - Phone:760-509-5273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5107878103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst