Provider Demographics
NPI:1447673140
Name:POTTS, JENNIFER K (LPCMH, NCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:POTTS
Suffix:
Gender:F
Credentials:LPCMH, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9788 WESTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN WYOMING
Mailing Address - State:DE
Mailing Address - Zip Code:19934-2305
Mailing Address - Country:US
Mailing Address - Phone:443-523-0559
Mailing Address - Fax:
Practice Address - Street 1:9788 WESTVILLE RD
Practice Address - Street 2:
Practice Address - City:CAMDEN WYOMING
Practice Address - State:DE
Practice Address - Zip Code:19934-2305
Practice Address - Country:US
Practice Address - Phone:443-523-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
DEPC-80020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550001Medicaid
MD609550004Medicaid