Provider Demographics
NPI:1013358647
Name:JACLYN S POTTS APRN-CRNA PC
Entity Type:Organization
Organization Name:JACLYN S POTTS APRN-CRNA PC
Other - Org Name:SOUTH CENTRAL ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:405-715-3610
Mailing Address - Street 1:P.O. BOX 268988
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126
Mailing Address - Country:US
Mailing Address - Phone:405-715-3610
Mailing Address - Fax:405-715-3612
Practice Address - Street 1:2002 12TH AVE NW STE C
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:405-715-3610
Practice Address - Fax:405-715-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0089907367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty