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General NPI Number Information
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NPI Number | 1801036272
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Entity Type | Organization
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Legal Business Name | VAUGHN R JEFFERSON PSYD MDIV LP LLC
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Dates
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Enumeration Date | 02/25/2009
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Last Update Date | 11/06/2014
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Provider Practice Location Address
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Address Line | 1030 WEST COUNTY ROAD E STE 260
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City | SHOREVIEW
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State | MN
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Zip | 55126
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Country | US
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Telephone | 651-483-1333
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Fax | 651-789-3088
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Provider Business Mailing Address
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Address Line | 1030 WEST COUNTY ROAD E STE 260
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City | SHOREVIEW
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State | MN
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Zip | 55126
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Country | US
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Telephone | 651-483-1333
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Fax | 651-789-3088
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VAUGHN ROBERT JEFFERSON
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Credential | PSYD
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Telephone | 651-483-1333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP 1666
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License Number State | MN
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