Provider Demographics
NPI:1457024770
Name:POTTER, JACQULYN
Entity Type:Individual
Prefix:
First Name:JACQULYN
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 DENNIS DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-6034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 DENNIS DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-6034
Practice Address - Country:US
Practice Address - Phone:973-727-6323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN