Healthcare Provider Details

I. General information

NPI: 1821478785
Provider Name (Legal Business Name): JENNIFER WHATLEY VAUGHN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 CLINTON PKWY
CLINTON MS
39056-5245
US

IV. Provider business mailing address

7520 WESTBANK EXPY SUITE D
MARRERO LA
70072-2354
US

V. Phone/Fax

Practice location:
  • Phone: 601-708-4205
  • Fax: 601-708-4707
Mailing address:
  • Phone: 504-371-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number09060
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: