Provider Demographics
NPI:1871240903
Name:POTTER, JADE A (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:A
Last Name:POTTER
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W MEADECREST DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-2439
Mailing Address - Country:US
Mailing Address - Phone:865-684-8295
Mailing Address - Fax:
Practice Address - Street 1:520 W SUMMIT HILL DR STE 601
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37902-2004
Practice Address - Country:US
Practice Address - Phone:865-505-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN231223163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-302373OtherIBCLC