Provider Demographics
NPI:1710308952
Name:VAUGHN D JACKSON, PLLC
Entity Type:Organization
Organization Name:VAUGHN D JACKSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-274-4500
Mailing Address - Street 1:P.O. BOX 272
Mailing Address - Street 2:416 MAIN
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140
Mailing Address - Country:US
Mailing Address - Phone:719-274-4500
Mailing Address - Fax:719-274-4504
Practice Address - Street 1:412 MAIN
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-274-4500
Practice Address - Fax:719-274-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31351261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty