Provider Demographics
NPI:1871378588
Name:POTTER, JACOB DANIEL (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:POTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 1325 N STE 150
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-8179
Mailing Address - Country:US
Mailing Address - Phone:435-867-6354
Mailing Address - Fax:435-867-1472
Practice Address - Street 1:110 W 1325 N STE 150
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-8179
Practice Address - Country:US
Practice Address - Phone:435-867-6354
Practice Address - Fax:435-867-1472
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12275004-1202111NP0017X, 111NR0400X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician