Provider Demographics
NPI:1629296579
Name:INGRAM, JON EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:EDWARD
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 E ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3441
Mailing Address - Country:US
Mailing Address - Phone:360-600-7685
Mailing Address - Fax:360-993-2777
Practice Address - Street 1:1514 E ST
Practice Address - Street 2:SUITE A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3441
Practice Address - Country:US
Practice Address - Phone:360-600-7685
Practice Address - Fax:360-993-2777
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1521103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist