Provider Demographics
NPI:1023257862
Name:VAUGHN, JENNIFER MEDINA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MEDINA
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9127 LONGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1604
Mailing Address - Country:US
Mailing Address - Phone:360-878-1110
Mailing Address - Fax:
Practice Address - Street 1:760 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4925
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91477106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist