Healthcare Provider Details

I. General information

NPI: 1639142250
Provider Name (Legal Business Name): JESSICA A. INGRAM MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PENN BLVD. SUITE 2240
PHILADELPHIA PA
19144
US

IV. Provider business mailing address

1 PENN BLVD. SUITE 2240
PHILADELPHIA PA
19144
US

V. Phone/Fax

Practice location:
  • Phone: 215-991-9440
  • Fax: 215-849-2975
Mailing address:
  • Phone: 215-991-9440
  • Fax: 215-849-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDN000551
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: