Healthcare Provider Details

I. General information

NPI: 1790933752
Provider Name (Legal Business Name): JESSICA S. VAUGHAN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 19TH AVE
MERIDIAN MS
39301-4116
US

IV. Provider business mailing address

1314 19TH AVE
MERIDIAN MS
39301-4116
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-4078
  • Fax: 601-703-4085
Mailing address:
  • Phone: 601-703-4078
  • Fax: 601-703-4085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR856479
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: