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General NPI Number Information
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NPI Number | 1184274607
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Entity Type | Individual
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Provider Name | LOGAN JADE GASKO MA
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Gender | Female
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Dates
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Enumeration Date | 09/17/2019
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Last Update Date | 09/17/2019
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Provider Practice Location Address
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Address Line | 1777 AXTELL DR STE 100
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City | TROY
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State | MI
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Zip | 48084-4400
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Country | US
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Telephone | 248-613-5377
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Fax |
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Provider Business Mailing Address
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Address Line | 19188 SOUTHAMPTON DR
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City | LIVONIA
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State | MI
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Zip | 48152-4106
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Country | US
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Telephone | 248-444-3250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301018085
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License Number State | MI
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