Healthcare Provider Details

I. General information

NPI: 1982114476
Provider Name (Legal Business Name): JENNIE LYNFRED LOGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3868 S CENTINELA AVE APT 12
LOS ANGELES CA
90066-4459
US

IV. Provider business mailing address

3868 S CENTINELA AVE APT 12
LOS ANGELES CA
90066-4459
US

V. Phone/Fax

Practice location:
  • Phone: 818-619-4041
  • Fax:
Mailing address:
  • Phone: 818-619-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number20293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: