Provider Demographics
NPI:1114211869
Name:INGRAM, JERILYN (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 GOLF HOUSE RD W., STE I PMB 102
Mailing Address - Street 2:
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6612 JOCKEY CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:WHITSETT
Practice Address - State:NC
Practice Address - Zip Code:27377
Practice Address - Country:US
Practice Address - Phone:336-230-5213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist