Provider Demographics
NPI:1770057820
Name:LOGAN-LANE, JEANNETTE (MSW)
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:LOGAN-LANE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24323 SEDLEY RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1305
Mailing Address - Country:US
Mailing Address - Phone:216-244-0497
Mailing Address - Fax:
Practice Address - Street 1:24323 SEDLEY RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1305
Practice Address - Country:US
Practice Address - Phone:216-244-0497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0901024104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty