Provider Demographics
NPI:1578277935
Name:DIVJAKA, KESJANA (LMT, CDT, MLD-C)
Entity Type:Individual
Prefix:
First Name:KESJANA
Middle Name:
Last Name:DIVJAKA
Suffix:
Gender:F
Credentials:LMT, CDT, MLD-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 MAIN ST APT C2
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-1375
Mailing Address - Country:US
Mailing Address - Phone:551-352-8695
Mailing Address - Fax:
Practice Address - Street 1:269 US HIGHWAY 46 STE 128
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-1438
Practice Address - Country:US
Practice Address - Phone:551-352-8695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01388300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist