Provider Demographics
NPI:1790383685
Name:POTTER, JANE (QSP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:QSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 36TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-5315
Mailing Address - Country:US
Mailing Address - Phone:701-340-5154
Mailing Address - Fax:
Practice Address - Street 1:915 36TH ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-5315
Practice Address - Country:US
Practice Address - Phone:701-340-5154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant