Provider Demographics
NPI:1427571678
Name:VAUGHN, JESSIE MICHELE (BCBA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:MICHELE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47320-1717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11807 ALLISONVILLE RD # 522
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2313
Practice Address - Country:US
Practice Address - Phone:765-730-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015015Medicaid