MEDICARE: JESSICA A. INGRAM MNT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1005X	Renal Nutrition Registered Dietitian	DN000551	PA

General Provider Information

NPI Number	:	1639142250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA A. INGRAM MNT

Provider Business Mailing Address
First Line	:	1 PENN BLVD.
Second Line	:	SUITE 2240
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144
Country	:	US
Telephone Number	:	215-991-9440
Fax Number	:	215-849-2975

Provider Business Practice Location Address
First Line	:	1 PENN BLVD.
Second Line	:	SUITE 2240
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144
Country	:	US
Telephone Number	:	215-991-9440
Fax Number	:	215-849-2975

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/08/2007

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