Provider Demographics
NPI:1033379516
Name:INGRAM, JENNY A (MS,CSAC,IDP-AT,PSIT)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:A
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS,CSAC,IDP-AT,PSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13380 W TREPANIA RD
Mailing Address - Street 2:LAC COURTE OREILLES COMMUNITY HEALTH CTR
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-638-5100
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:13380 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-638-5116
Practice Address - Fax:715-638-6107
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14547-131101YA0400X
WI2831101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39172000Medicaid