Basic Information
| Provider Information | |||||||||
| NPI: | 1275920373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | IVANKA TREIDL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 N 1900 E | ||||||||
| Address2: | #1A071 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841322140 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 N 1900 E | ||||||||
| Address2: | #1A071 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817553 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 9529333-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.