Provider Demographics
NPI:1689116311
Name:POTESTA, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:POTESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:MOUNTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9891 MONTGOMERY RD # 340
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10500 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH373899163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse