Healthcare Provider Details

I. General information

NPI: 1215690946
Provider Name (Legal Business Name): LOGAN HUTCHINSON OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1577 ROBERTS DR STE 320
JACKSONVILLE BEACH FL
32250-3266
US

IV. Provider business mailing address

PO BOX 117345
ATLANTA GA
30368-7345
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-3324
  • Fax:
Mailing address:
  • Phone: 904-346-3465
  • Fax: 904-858-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT22415
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: