MEDICARE: JENA MAREE VAUGHN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	2010017067	MO

General Provider Information

NPI Number	:	1558601484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENA MAREE VAUGHN LMT

Provider Business Mailing Address
First Line	:	2487 HARTLAND AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63114-5033
Country	:	US
Telephone Number	:	314-426-6702
Fax Number	:

Provider Business Practice Location Address
First Line	:	1614 S BIG BEND BLVD
Second Line	:
City	:	RICHMOND HTS
State	:	MO
Zip	:	63117-2208
Country	:	US
Telephone Number	:	314-368-1689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2013
Last Update Date	:	03/01/2013

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