Provider Demographics
NPI:1114125978
Name:INGRAM, JENNIFER MAVRICK (LMHC, CAP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MAVRICK
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMHC, CAP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MAVRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, CAP
Mailing Address - Street 1:1301 SEMINOLE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-8173
Mailing Address - Country:US
Mailing Address - Phone:727-213-5379
Mailing Address - Fax:727-213-5370
Practice Address - Street 1:1301 SEMINOLE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-8173
Practice Address - Country:US
Practice Address - Phone:727-213-5379
Practice Address - Fax:272-213-5370
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2868101YA0400X
FLMH8176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11691411OtherCAQH ID NUMBER