Provider Demographics
NPI:1962160929
Name:POTTER, JESSE R (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:POTTER
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:R
Other - Last Name:LITTLEFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 COLD BEAR DR
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-3343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6942
Practice Address - Country:US
Practice Address - Phone:207-773-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT8242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty