Provider Demographics
NPI:1215296835
Name:VAUGHN, JESSICA N
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 S COLORADO ST STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7275
Mailing Address - Country:US
Mailing Address - Phone:662-335-8332
Mailing Address - Fax:662-335-8852
Practice Address - Street 1:1707 S COLORADO ST STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7275
Practice Address - Country:US
Practice Address - Phone:662-335-8332
Practice Address - Fax:662-335-8852
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640925683OtherBLUE CROSS BLUE SHIELD
MS09015486Medicaid
MS256579OtherMEDICARE