MEDICARE: JESSICA LOGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1073280335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LOGAN

Provider Business Mailing Address
First Line	:	2479 PEACHTREE RD NE APT 308
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-4129
Country	:	US
Telephone Number	:	404-308-0191
Fax Number	:

Provider Business Practice Location Address
First Line	:	2479 PEACHTREE RD NE APT 308
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-4129
Country	:	US
Telephone Number	:	404-308-0191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2021
Last Update Date	:	08/25/2021

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Directions to “ JESSICA LOGAN ” Practice Location

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