Provider Demographics
NPI:1699056374
Name:RYAN, JESSICA LORRAINE (DPT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LORRAINE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7673 SUMMIT PEAK DR APT D301
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5822
Mailing Address - Country:US
Mailing Address - Phone:701-330-6884
Mailing Address - Fax:
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8069264-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist