Provider Demographics
NPI:1841304094
Name:LOGSTON, JENNIFER KEELY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KEELY
Last Name:LOGSTON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 OGDEN AVE # 112
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2829
Mailing Address - Country:US
Mailing Address - Phone:630-528-8855
Mailing Address - Fax:630-241-4388
Practice Address - Street 1:5010 FAIRVIEW AVE STE 5
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5201
Practice Address - Country:US
Practice Address - Phone:630-528-8855
Practice Address - Fax:630-541-6557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490086321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002225381OtherBLUE CROSS BLUE SHIELD