Healthcare Provider Details

I. General information

NPI: 1588071237
Provider Name (Legal Business Name): JESSE LOGUE M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12650 HAMILTON CROSSING BLVD
CARMEL IN
46032-5400
US

IV. Provider business mailing address

2931 E BIDDLE ST
BALTIMORE MD
21213-3939
US

V. Phone/Fax

Practice location:
  • Phone: 317-249-2242
  • Fax: 442-896-7988
Mailing address:
  • Phone: 443-923-1886
  • Fax: 443-923-1895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043337B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-17462
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: