Healthcare Provider Details

I. General information

NPI: 1063651040
Provider Name (Legal Business Name): JENNIFER L LOGAN LMHC, LASW, CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD
VANCOUVER WA
98661-3753
US

IV. Provider business mailing address

PO BOX 1678
VANCOUVER WA
98668-1678
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: