Provider Demographics
NPI:1710730973
Name:POTTS, JIMMIE JR
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
Last Name:POTTS
Suffix:JR
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 1:36744 HARPER AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-5877
Mailing Address - Country:US
Mailing Address - Phone:586-222-4312
Mailing Address - Fax:
Practice Address - Street 1:36744 HARPER AVE APT 305
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-5877
Practice Address - Country:US
Practice Address - Phone:158-622-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager