Provider Demographics
NPI:1326188830
Name:VAUGHN, JACKIE (MA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:1570 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2523
Practice Address - Country:US
Practice Address - Phone:423-224-1300
Practice Address - Fax:423-224-1375
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor