Provider Demographics
NPI:1265832109
Name:POTTER, JESSE (MED, LPC, LCDC)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MED, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SAYLES BLVD.
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605
Mailing Address - Country:US
Mailing Address - Phone:325-793-4881
Mailing Address - Fax:
Practice Address - Street 1:1400 SAYLES BLVD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4236
Practice Address - Country:US
Practice Address - Phone:325-793-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11807101YA0400X
TX69219101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)