Provider Demographics
NPI:1689097933
Name:INGRAM, JACKLYN M (MED)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:M
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-5639
Mailing Address - Country:US
Mailing Address - Phone:405-557-1655
Mailing Address - Fax:405-525-0677
Practice Address - Street 1:1132 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-5639
Practice Address - Country:US
Practice Address - Phone:405-557-1655
Practice Address - Fax:405-525-0677
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool