Provider Demographics
NPI:1013234434
Name:POTOKAR, JACQUELINE M (CERTIFIED CARE GIVER)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:POTOKAR
Suffix:
Gender:F
Credentials:CERTIFIED CARE GIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5175 S KINGS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-3337
Mailing Address - Country:US
Mailing Address - Phone:602-708-0546
Mailing Address - Fax:
Practice Address - Street 1:5175 S KINGS RANCH RD
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-3337
Practice Address - Country:US
Practice Address - Phone:602-708-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-24
Last Update Date:2010-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALTP0141372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion