Provider Demographics
NPI:1104211366
Name:POTTER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 POST ST
Mailing Address - Street 2:STE 205
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3473
Mailing Address - Country:US
Mailing Address - Phone:415-292-0638
Mailing Address - Fax:415-292-0718
Practice Address - Street 1:1 SHRADER ST STE 510
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1034
Practice Address - Country:US
Practice Address - Phone:415-759-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5424213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty