Individual
LOGAN J JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3623 LATROBE DR STE 216, CHARLOTTE, NC 28211-2117
(704) 332-1291
Mailing address
PO BOX 221249, CHARLOTTE, NC 28222-1249
(704) 332-1291
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
0101285232
VA
2085R0202X
Diagnostic Radiology Physician
125077323
IL
2085R0202X
Diagnostic Radiology Physician
Primary
2025-03621
NC
390200000X
Student in an Organized Health Care Education/Training Program
LL84285
SC
Other
Enumeration date
03/25/2020
Last updated
11/03/2025
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