Healthcare Provider Details

I. General information

NPI: 1578488730
Provider Name (Legal Business Name): LOGAN GILBERTSON OTR4172
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MARSHALL RD
JACKSONVILLE AR
72076-3749
US

IV. Provider business mailing address

519 MARSHALL RD
JACKSONVILLE AR
72076-3749
US

V. Phone/Fax

Practice location:
  • Phone: 501-982-9511
  • Fax: 501-982-9512
Mailing address:
  • Phone: 501-982-9511
  • Fax: 501-982-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR4172
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: