Provider Demographics
NPI:1740060029
Name:LOGAN, JENNIFER ROSE (LSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3856 N LEAVITT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3892
Mailing Address - Country:US
Mailing Address - Phone:708-289-7454
Mailing Address - Fax:
Practice Address - Street 1:3047 N LINCOLN AVE UNIT 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4274
Practice Address - Country:US
Practice Address - Phone:773-494-5505
Practice Address - Fax:773-857-1164
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109078104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker