Healthcare Provider Details

I. General information

NPI: 1447907472
Provider Name (Legal Business Name): JORDAN POTTS RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 IRIS DR APT 1409
CHARLOTTE NC
28205-6097
US

IV. Provider business mailing address

1310 IRIS DR APT 1409
CHARLOTTE NC
28205-6097
US

V. Phone/Fax

Practice location:
  • Phone: 614-561-2618
  • Fax:
Mailing address:
  • Phone: 614-561-2618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80784
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: