Basic Information
| Provider Information | |||||||||
| NPI: | 1295762870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAUGHN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PCC-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAUGHN-BROWN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 204 COOK RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5136952952 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 KINGSVIEW DR | ||||||||
| Address2: | BLDG A | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5132287846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E-0003879-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 62-00070 | 01 | OH | UNITED PROVIDER ID | OTHER | 000000250852 | 01 | OH | ANTHEM PIN | OTHER | 11749390 | 01 | CAQH # | OTHER |