Healthcare Provider Details

I. General information

NPI: 1306762117
Provider Name (Legal Business Name): DR. JACK PHILLIP LOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 SAN DIMAS ST STE B
BAKERSFIELD CA
93301-1497
US

IV. Provider business mailing address

2901 SKYLINE BLVD
BAKERSFIELD CA
93305-1863
US

V. Phone/Fax

Practice location:
  • Phone: 661-327-0835
  • Fax:
Mailing address:
  • Phone: 661-327-0835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: