Healthcare Provider Details

I. General information

NPI: 1609290691
Provider Name (Legal Business Name): JENNIFER VAUGHN THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25282 HAZELWOOD DR STE 1
NISSWA MN
56468-2976
US

IV. Provider business mailing address

4682 WILDERNESS CT # 103
BRAINERD MN
56401-2834
US

V. Phone/Fax

Practice location:
  • Phone: 218-820-7671
  • Fax: 218-600-5500
Mailing address:
  • Phone: 218-820-6626
  • Fax: 218-600-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2090
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANNE-SONG VAUGHN
Title or Position: OWNER
Credential: LMFT
Phone: 218-820-6626