Provider Demographics
NPI:1457344376
Name:LOGAN, JENNIFER COLEMAN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COLEMAN
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241B FREEDOM WAY
Mailing Address - Street 2:JACKSONVILLE VA CBOC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28544-1418
Mailing Address - Country:US
Mailing Address - Phone:619-246-6030
Mailing Address - Fax:
Practice Address - Street 1:241B FREEDOM WAY
Practice Address - Street 2:JACKSONVILLE VA CBOC
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28544-1418
Practice Address - Country:US
Practice Address - Phone:619-246-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907908Medicaid
2065728Medicare Oscar/Certification
H40083Medicare UPIN