Healthcare Provider Details

I. General information

NPI: 1417209347
Provider Name (Legal Business Name): JENNIFER MAE POTTER MS, ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MAE HACKER

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE STE 200
ELKHART IN
46514-2485
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-294-8404
  • Fax: 574-523-1642
Mailing address:
  • Phone: 574-647-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71004185A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: