Healthcare Provider Details

I. General information

NPI: 1124370226
Provider Name (Legal Business Name): JENNIFER D LOGAN PH.D, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER D BRIDGES

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 APPALOOSA CIR
GOODFIELD IL
61742-9300
US

IV. Provider business mailing address

103 APPALOOSA CIR
GOODFIELD IL
61742-9300
US

V. Phone/Fax

Practice location:
  • Phone: 309-360-2268
  • Fax:
Mailing address:
  • Phone: 309-360-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178006924
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180012370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: