Provider Demographics
NPI:1629306980
Name:POTEET, JERRY DALE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DALE
Last Name:POTEET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 THOMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2241
Mailing Address - Country:US
Mailing Address - Phone:660-826-3700
Mailing Address - Fax:
Practice Address - Street 1:904 THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2241
Practice Address - Country:US
Practice Address - Phone:660-826-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO231H00000X, 237600000X
MO2002012707237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter