Provider Demographics
NPI:1639142250
Name:INGRAM, JESSICA A (MNT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PENN BLVD.
Mailing Address - Street 2:SUITE 2240
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144
Mailing Address - Country:US
Mailing Address - Phone:215-991-9440
Mailing Address - Fax:215-849-2975
Practice Address - Street 1:1 PENN BLVD.
Practice Address - Street 2:SUITE 2240
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144
Practice Address - Country:US
Practice Address - Phone:215-991-9440
Practice Address - Fax:215-849-2975
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000551133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA085102E1EMedicare ID - Type Unspecified