Provider Demographics
NPI:1255860581
Name:VAUGHN, JEANINE (LMFT)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2112
Mailing Address - Country:US
Mailing Address - Phone:860-886-1508
Mailing Address - Fax:860-889-4606
Practice Address - Street 1:75 GRANITE ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5730
Practice Address - Country:US
Practice Address - Phone:860-437-4550
Practice Address - Fax:860-437-4552
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CT2065106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist