Provider Demographics
NPI:1679364897
Name:POTTER, BRANDON JAY
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAY
Last Name:POTTER
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 1:1081 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3542
Mailing Address - Country:US
Mailing Address - Phone:619-535-7644
Mailing Address - Fax:
Practice Address - Street 1:1081 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3542
Practice Address - Country:US
Practice Address - Phone:619-535-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB1337736106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician