Provider Demographics
NPI:1427081413
Name:JEFFERSON, VAUGHN ROBERT JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:VAUGHN
Middle Name:ROBERT
Last Name:JEFFERSON
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
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Mailing Address - Street 1:1030 WEST COUNTY ROAD E
Mailing Address - Street 2:STE 260
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126
Mailing Address - Country:US
Mailing Address - Phone:651-483-1333
Mailing Address - Fax:651-789-3088
Practice Address - Street 1:1030 WEST COUNTY ROAD E
Practice Address - Street 2:STE 260
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:651-483-1333
Practice Address - Fax:651-789-3088
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP1666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN688750300Medicaid
MNC05301Medicare PIN
MN680002685Medicare PIN