Provider Demographics
NPI:1689873374
Name:VAUGHAN, JENNIFER LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12597 WALSINGHAM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3624
Mailing Address - Country:US
Mailing Address - Phone:727-688-0555
Mailing Address - Fax:
Practice Address - Street 1:12597 WALSINGHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3624
Practice Address - Country:US
Practice Address - Phone:727-688-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886437300Medicaid
FL886437396OtherMEDICAID WAIVER