Provider Demographics
NPI:1871942961
Name:DIVERS, JAKE E IV (PT, DPT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:E
Last Name:DIVERS
Suffix:IV
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 VINYARD RD
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-3632
Mailing Address - Country:US
Mailing Address - Phone:540-343-0466
Mailing Address - Fax:540-345-2261
Practice Address - Street 1:1110 VINYARD RD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-3632
Practice Address - Country:US
Practice Address - Phone:540-343-0466
Practice Address - Fax:540-345-2261
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist