Provider Demographics
NPI:1376075192
Name:POTTER, JARED (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JARED
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2050 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1465
Practice Address - Country:US
Practice Address - Phone:404-603-4253
Practice Address - Fax:404-603-4426
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA927292081P0301X
KYIP1557208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation