Provider Demographics
NPI:1801575139
Name:POTTER, JESSICA (COTA/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 EDS LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-5741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13857 APPLE HARVEST DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-6199
Practice Address - Country:US
Practice Address - Phone:304-596-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2039224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant