Healthcare Provider Details

I. General information

NPI: 1922053123
Provider Name (Legal Business Name): JENNIFER A DIVECCHIA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CHESTNUT
DENTON TX
76201
US

IV. Provider business mailing address

1155 UNION CIR # 305160
DENTON TX
76203-5017
US

V. Phone/Fax

Practice location:
  • Phone: 940-565-2333
  • Fax: 940-565-3190
Mailing address:
  • Phone: 940-369-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP103616
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: