Provider Demographics
NPI:1801036272
Name:VAUGHN R JEFFERSON PSYD MDIV LP LLC
Entity Type:Organization
Organization Name:VAUGHN R JEFFERSON PSYD MDIV LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:651-483-1333
Mailing Address - Street 1:1030 WEST COUNTY ROAD E
Mailing Address - Street 2:STE 260
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126
Mailing Address - Country:US
Mailing Address - Phone:651-483-1333
Mailing Address - Fax:651-789-3088
Practice Address - Street 1:1030 WEST COUNTY ROAD E
Practice Address - Street 2:STE 260
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:651-483-1333
Practice Address - Fax:651-789-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1666103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN688750300Medicaid
MN680002685Medicare PIN
MNC05301Medicare PIN