Provider Demographics
NPI:1063646529
Name:DIVITA, JENNIFER (DO)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:DIVITA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3302
Mailing Address - Country:US
Mailing Address - Phone:304-388-2709
Mailing Address - Fax:304-344-1755
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:STE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2709
Practice Address - Fax:304-344-1755
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV2474208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023323Medicaid