Provider Demographics
NPI:1053042689
Name:POTTER, JENNIFER (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BLAND HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-7499
Mailing Address - Country:US
Mailing Address - Phone:252-560-1991
Mailing Address - Fax:
Practice Address - Street 1:2700 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9494
Practice Address - Country:US
Practice Address - Phone:919-736-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016417363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine