Provider Demographics
NPI:1710260708
Name:VAUGHN, JENNIFER ANNE-SONG (MS)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANNE-SONG
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANNE-SONG
Other - Last Name:MAXFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:12756 LAKEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-7433
Mailing Address - Country:US
Mailing Address - Phone:218-851-5484
Mailing Address - Fax:
Practice Address - Street 1:617 OAK ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3610
Practice Address - Country:US
Practice Address - Phone:218-851-5484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2014-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist