Provider Demographics
NPI:1407032493
Name:INGRAM, JILL MEREDITH (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:MEREDITH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 LISBON LN APT 203
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3176
Mailing Address - Country:US
Mailing Address - Phone:757-416-7870
Mailing Address - Fax:
Practice Address - Street 1:1309 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2205
Practice Address - Country:US
Practice Address - Phone:757-461-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6095224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant