Provider Demographics
NPI:1548904774
Name:JARTA, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JARTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8623 W FOSTER AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-2726
Mailing Address - Country:US
Mailing Address - Phone:773-865-4141
Mailing Address - Fax:
Practice Address - Street 1:339 9TH AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6429
Practice Address - Country:US
Practice Address - Phone:708-354-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008947225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant