Provider Demographics
NPI:1144769043
Name:POTEAT, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:POTEAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:YARBROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 7TH ST
Mailing Address - Street 2:RACINE, WI 53403
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1222
Mailing Address - Country:US
Mailing Address - Phone:262-634-2391
Mailing Address - Fax:
Practice Address - Street 1:420 7TH ST
Practice Address - Street 2:RACINE, WI 53403
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1222
Practice Address - Country:US
Practice Address - Phone:262-634-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17188-130101YA0400X
WI2264-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)