Provider Demographics
NPI:1376864256
Name:VAUGHN, JASON M (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-277-0795
Mailing Address - Fax:208-277-0775
Practice Address - Street 1:17355 BOONES FERRY RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:503-635-0844
Practice Address - Fax:503-635-0812
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62442251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic