MEDICARE: MRS. JENNAFER DAWN LOGAN MS, RD/LD

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	133V00000X	Registered Dietitian	525	OK

General Provider Information

NPI Number	:	1811184880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNAFER DAWN LOGAN MS, RD/LD

Provider Business Mailing Address
First Line	:	5601 NW 72ND ST STE 200
Second Line	:
City	:	WARR ACRES
State	:	OK
Zip	:	73132-5920
Country	:	US
Telephone Number	:	405-816-2898
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 NW 72ND ST STE 200
Second Line	:
City	:	WARR ACRES
State	:	OK
Zip	:	73132-5920
Country	:	US
Telephone Number	:	405-603-1941
Fax Number	:

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

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	09/16/2016

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