Provider Demographics
NPI:1437190543
Name:POTTER, JENNIFER BAILEY (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BAILEY
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:BUILDING D, SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-7790
Practice Address - Fax:972-566-5819
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04401363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181617501Medicaid
TX181617502Medicaid
TXP01824297OtherRAILROAD
TX8G6410Medicare PIN
TX463829YKYCMedicare PIN
TX181617502Medicaid