Provider Demographics
NPI:1013446509
Name:TANYCH, JILLIAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:
Last Name:TANYCH
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:MERCY HOSPITAL
Mailing Address - Street 2:4050 COON RAPIDS BLVD NW
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-236-8574
Mailing Address - Fax:763-236-8990
Practice Address - Street 1:MERCY HOSPITAL
Practice Address - Street 2:4050 COON RAPIDS BLVD NW
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-236-8574
Practice Address - Fax:763-236-8990
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist