Provider Demographics
NPI:1710173968
Name:DIVINE, JONATHAN (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DIVINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9560 CROSSHILL BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-5827
Mailing Address - Country:US
Mailing Address - Phone:904-308-7792
Mailing Address - Fax:904-779-7335
Practice Address - Street 1:9560 CROSSHILL BLVD STE 110
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5827
Practice Address - Country:US
Practice Address - Phone:904-308-7792
Practice Address - Fax:904-779-7335
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 1671207Q00000X
FLOS 10858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine