Healthcare Provider Details

I. General information

NPI: 1184043903
Provider Name (Legal Business Name): JENNIFER KRISTIN LOGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-8650
  • Fax: 321-841-3794
Mailing address:
  • Phone: 321-841-8650
  • Fax: 321-841-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME140382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: