Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist |
NPI | 1023200581 |
---|---|
Provider Name | Jamilah Q Logan |
First Address | Phoenix, AZ 85043-5065 |
Second Address | Tolleson, AZ 85353-2941 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2007 |
Last Update Date | 17/08/2007 |