Provider Demographics
NPI:1699781716
Name:POTTS, JACKIE L (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:POTTS
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N HOLTZCLAW - SUITE 200
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1240
Mailing Address - Country:US
Mailing Address - Phone:423-622-6900
Mailing Address - Fax:423-622-4834
Practice Address - Street 1:600 N HOLTZCLAW - SUITE 200
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1240
Practice Address - Country:US
Practice Address - Phone:426-622-6900
Practice Address - Fax:423-622-4834
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000001594235Z00000X
GASLP004960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4000592Medicaid
TN4000592OtherBCBST
TN4640001OtherUNITEDHEALTHCARE
TN4640001OtherUNITEDHEALTHCARE