Healthcare Provider Details

I. General information

NPI: 1336557867
Provider Name (Legal Business Name): JONATHAN INGRAM PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 S PIONEER WAY STE 165
MOSES LAKE WA
98837-4637
US

IV. Provider business mailing address

660 S COOLIDGE ST
MOSES LAKE WA
98837-1872
US

V. Phone/Fax

Practice location:
  • Phone: 509-793-9780
  • Fax: 509-764-3246
Mailing address:
  • Phone: 509-793-9715
  • Fax: 509-764-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60491883
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: