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General NPI Number Information
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NPI Number | 1609930395
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Entity Type | Individual
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Provider Name | JESSE THOMAS LOGAN LCMFT
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Gender | Male
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 10/28/2015
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Provider Practice Location Address
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Address Line | 8901 WISCONSIN AVE BLDG. 19, 6504
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City | BETHESDA
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State | MD
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Zip | 20889-5600
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Country | US
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Telephone | 301-400-1928
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Fax |
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Provider Business Mailing Address
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Address Line | 16070 A E MULLINIX RD
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City | WOODBINE
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State | MD
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Zip | 21797-8438
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Country | US
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Telephone | 410-489-4398
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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 | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number | LC2001
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LCM422
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License Number State | MD
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