Provider Demographics
NPI:1609825769
Name:DEVITA, JENNIFER R (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:R
Last Name:DEVITA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 HINESBURG RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7613
Mailing Address - Country:US
Mailing Address - Phone:802-862-1808
Mailing Address - Fax:
Practice Address - Street 1:1100 HINESBURG RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7613
Practice Address - Country:US
Practice Address - Phone:802-862-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030000330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTP00218676OtherRAIL ROAD MEDICARE
VT1010544Medicaid
VT1010544Medicaid