Provider Demographics
NPI:1023242534
Name:POTTER, JEREMY (LICSW)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SAXON RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1521
Mailing Address - Country:US
Mailing Address - Phone:508-395-6857
Mailing Address - Fax:
Practice Address - Street 1:340 MAPLE ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3200
Practice Address - Country:US
Practice Address - Phone:508-485-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health