Healthcare Provider Details

I. General information

NPI: 1811184880
Provider Name (Legal Business Name): JENNAFER DAWN LOGAN MS, RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 NW 72ND ST STE 200
WARR ACRES OK
73132-5920
US

IV. Provider business mailing address

5601 NW 72ND ST STE 200
WARR ACRES OK
73132-5920
US

V. Phone/Fax

Practice location:
  • Phone: 405-603-1941
  • Fax:
Mailing address:
  • Phone: 405-816-2898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number525
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: