Provider Demographics
NPI:1336550557
Name:DIVITA, JILL E (RN)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:E
Last Name:DIVITA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:E
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1230 N. HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506
Mailing Address - Country:US
Mailing Address - Phone:630-966-4319
Mailing Address - Fax:630-859-3841
Practice Address - Street 1:1230 N. HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506
Practice Address - Country:US
Practice Address - Phone:630-966-4319
Practice Address - Fax:630-859-3841
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041219070163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult