Healthcare Provider Details

I. General information

NPI: 1245828201
Provider Name (Legal Business Name): JESSICA ROSE VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90971 S WILLAMETTE ST
COBURG OR
97408-9206
US

IV. Provider business mailing address

1295 RIVER RD
EUGENE OR
97404-3537
US

V. Phone/Fax

Practice location:
  • Phone: 833-628-5433
  • Fax:
Mailing address:
  • Phone: 541-521-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number26072
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: