Healthcare Provider Details

I. General information

NPI: 1285720771
Provider Name (Legal Business Name): JESSICA M POTVIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W THOMAS RD STE 315
PHOENIX AZ
85013-4422
US

IV. Provider business mailing address

222 W THOMAS RD STE 315
PHOENIX AZ
85013-4422
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3671
  • Fax: 602-406-6115
Mailing address:
  • Phone: 602-406-3671
  • Fax: 602-406-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3807
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: