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General NPI Number Information
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NPI Number | 1376628248
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Entity Type | Individual
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Provider Name | JACKIE L. INGRAM LMP
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Gender | Female
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 3912 MARTIN WAY E SUITE B
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City | OLYMPIA
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State | WA
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Zip | 98506
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Country | US
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Telephone | 360-459-9780
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Fax | 360-412-0581
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Provider Business Mailing Address
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Address Line | 460 W BULB FARM RD
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City | SHELTON
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State | WA
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Zip | 98584-9154
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Country | US
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Telephone | 360-490-6490
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Fax | 360-412-0581
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA00011670
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License Number State | WA
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