Provider Demographics
NPI:1215941471
Name:DEVINE, JEREMY (MSPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DEVINE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 LEWANDOWSKI ST
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-2500
Mailing Address - Country:US
Mailing Address - Phone:201-933-9959
Mailing Address - Fax:201-933-9958
Practice Address - Street 1:418 LEWANDOWSKI ST
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-2500
Practice Address - Country:US
Practice Address - Phone:201-933-9959
Practice Address - Fax:201-933-9958
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA07596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ067466N5CMedicare ID - Type Unspecified