Provider Demographics
NPI:1245828201
Name:VAUGHAN, JESSICA ROSE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:VAUGHAN
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 1:1295 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3537
Mailing Address - Country:US
Mailing Address - Phone:541-521-6766
Mailing Address - Fax:
Practice Address - Street 1:90971 S WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9206
Practice Address - Country:US
Practice Address - Phone:833-628-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR26072Medicaid