Provider Demographics
NPI:1184065930
Name:DIVINE, JESSICA WALL (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:WALL
Last Name:DIVINE
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:LAUREN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1080 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-454-4100
Mailing Address - Fax:
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:831-454-4488
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116026459207Q00000X
CA145258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine