Provider Demographics
NPI:1043273717
Name:DIVITA, JENNIFER FERGUSON (MPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FERGUSON
Last Name:DIVITA
Suffix:
Gender:F
Credentials:MPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:99 WOLF CREEK BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4968
Mailing Address - Country:US
Mailing Address - Phone:302-734-8000
Mailing Address - Fax:
Practice Address - Street 1:99 WOLF CREEK BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4968
Practice Address - Country:US
Practice Address - Phone:302-734-8000
Practice Address - Fax:302-734-0102
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001606225100000X, 2251E1200X, 2251G0304X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE146729900OtherDEPART OF LABOR
DE2623565000OtherAMERIHEALTH
DE011720S93Medicare ID - Type Unspecified
DE146729900OtherDEPART OF LABOR