Provider Demographics
NPI:1275743692
Name:POTTER, JILL ANN (DC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:POTTER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:ANN
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1637 NEVADA HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-1930
Mailing Address - Country:US
Mailing Address - Phone:702-294-4944
Mailing Address - Fax:702-294-4946
Practice Address - Street 1:1637 NEVADA HWY
Practice Address - Street 2:SUITE B
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1930
Practice Address - Country:US
Practice Address - Phone:702-294-4944
Practice Address - Fax:702-294-4946
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV39518Medicare ID - Type Unspecified