Provider Demographics
NPI:1982114476
Name:LOGUE, JENNIE LYNFRED
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LYNFRED
Last Name:LOGUE
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 1:3868 S CENTINELA AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4459
Mailing Address - Country:US
Mailing Address - Phone:818-619-4041
Mailing Address - Fax:
Practice Address - Street 1:3868 S CENTINELA AVE APT 12
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4459
Practice Address - Country:US
Practice Address - Phone:818-619-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20293111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner