Provider Demographics
NPI:1912316654
Name:RYAN, JEANNA TACHIKI (RD)
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:TACHIKI
Last Name:RYAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JEANNA
Other - Middle Name:HANAKO
Other - Last Name:TACHIKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2330 E CAPRICE CT
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-6800
Mailing Address - Country:US
Mailing Address - Phone:801-414-8890
Mailing Address - Fax:
Practice Address - Street 1:243 E 6100 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7302
Practice Address - Country:US
Practice Address - Phone:801-414-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT87742931206207N00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology