Provider Demographics
NPI:1245348812
Name:POTTS, JACK X (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:POTTS
Suffix:X
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2002
Mailing Address - Country:US
Mailing Address - Phone:602-274-5494
Mailing Address - Fax:602-264-5566
Practice Address - Street 1:221 E INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2002
Practice Address - Country:US
Practice Address - Phone:602-274-5494
Practice Address - Fax:602-264-5566
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ121852084F0202X
AZ121852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry