Provider Demographics
NPI:1417209347
Name:POTTER, JENNIFER MAE (MS, ANP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS, ANP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MAE
Other - Last Name:HACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2485
Practice Address - Country:US
Practice Address - Phone:574-294-8404
Practice Address - Fax:574-523-1642
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004185A363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201271860Medicaid
IN236040322OtherMEDICARE PTAN
IN327270012OtherMEDICARE PTAN
IN71004185AOtherLICENSE NUMBER