Provider Demographics
NPI:1558601484
Name:VAUGHN, JENA MAREE (LMT)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:MAREE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2487 HARTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5033
Mailing Address - Country:US
Mailing Address - Phone:314-426-6702
Mailing Address - Fax:
Practice Address - Street 1:1614 S BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND HTS
Practice Address - State:MO
Practice Address - Zip Code:63117-2208
Practice Address - Country:US
Practice Address - Phone:314-368-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010017067225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist