Provider Demographics
NPI:1467505727
Name:POTTER, JEFFERY BRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:BRENT
Last Name:POTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HOLDERRIETH BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4553
Mailing Address - Country:US
Mailing Address - Phone:832-698-2561
Mailing Address - Fax:832-698-2561
Practice Address - Street 1:444 HOLDERRIETH BLVD STE 4
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4553
Practice Address - Country:US
Practice Address - Phone:832-698-2561
Practice Address - Fax:832-698-2561
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9837111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX608091OtherBCBSTX PARPLAN PROVIDER #
TXH060809101OtherBCBSTX PROVIDER NUMBER
TX3721239OtherAETNA PROVIDER NUMBER
TX1045376OtherBCBSTX BLUE LINK ACCESS C
TX611770Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER