Provider Demographics
NPI:1811184880
Name:LOGAN, JENNAFER DAWN (MS, RD/LD)
Entity type:Individual
Prefix:MRS
First Name:JENNAFER
Middle Name:DAWN
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 NW 72ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5920
Mailing Address - Country:US
Mailing Address - Phone:405-816-2898
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 72ND ST STE 200
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5920
Practice Address - Country:US
Practice Address - Phone:405-603-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK525133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered