MEDICARE: KATHLEEN M LOGAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	25358	MN
2	2084P0800X	Psychiatry Physician	11343A	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699752089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M LOGAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 428
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-0428
Country	:	US
Telephone Number	:	307-739-4818
Fax Number	:	888-329-5701

Provider Business Practice Location Address
First Line	:	555 E BROADWAY AVE STE 204
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8640
Country	:	US
Telephone Number	:	307-739-4818
Fax Number	:	888-329-5701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	02/10/2021

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Directions to “ KATHLEEN M LOGAN M.D.” Practice Location

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