Basic Information
| Provider Information | |||||||||
| NPI: | 1376864256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAUGHN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082770795 | ||||||||
| FaxNumber: | 2082770775 | ||||||||
| Practice Location | |||||||||
| Address1: | 17355 BOONES FERRY RD STE B | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036350844 | ||||||||
| FaxNumber: | 5036350812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 6244 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.