Basic Information
| Provider Information | |||||||||
| NPI: | 1013358647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACLYN S POTTS APRN-CRNA PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CENTRAL ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 268988 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057153610 | ||||||||
| FaxNumber: | 4057153612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 12TH AVE NW STE C | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057153610 | ||||||||
| FaxNumber: | 4057153612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | POTTS | ||||||||
| AuthorizedOfficialFirstName: | JACLYN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4057153610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0089907 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.