Provider Demographics
NPI:1558517649
Name:POTTER, JENNIFER RENEE (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:POTTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 RENITA CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8702
Mailing Address - Country:US
Mailing Address - Phone:405-837-5841
Mailing Address - Fax:
Practice Address - Street 1:14453 SE 29TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-6541
Practice Address - Country:US
Practice Address - Phone:405-741-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226900AMedicaid
OK200226900AMedicaid