Provider Demographics
NPI:1033204128
Name:VAUGHT, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VAUGHT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2540
Mailing Address - Country:US
Mailing Address - Phone:504-464-4153
Mailing Address - Fax:504-464-9949
Practice Address - Street 1:300 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2540
Practice Address - Country:US
Practice Address - Phone:504-464-4153
Practice Address - Fax:504-464-9949
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1376-508T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1099155Medicaid
LA4B296Medicare ID - Type Unspecified
LA1099155Medicaid