Provider Demographics
NPI:1578036307
Name:POTTER, JESSIE L (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:L
Last Name:POTTER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9955 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9389
Mailing Address - Country:US
Mailing Address - Phone:248-224-0374
Mailing Address - Fax:
Practice Address - Street 1:6231 N CANTON CENTER RD STE 109
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2692
Practice Address - Country:US
Practice Address - Phone:734-455-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor