Provider Demographics
NPI:1821974999
Name:POTIA, JACKIE ANN
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANN
Last Name:POTIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1046 HEATHER CIR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1090
Mailing Address - Country:US
Mailing Address - Phone:575-740-3189
Mailing Address - Fax:
Practice Address - Street 1:1300 AVENIDA DE MESILLA STE 225
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3993
Practice Address - Country:US
Practice Address - Phone:575-297-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker