Provider Demographics
NPI:1689186611
Name:INGRAM, JACQULYN C (LMT)
Entity Type:Individual
Prefix:MS
First Name:JACQULYN
Middle Name:C
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10607 DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-3604
Mailing Address - Country:US
Mailing Address - Phone:216-299-5280
Mailing Address - Fax:
Practice Address - Street 1:10607 DREXEL AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3604
Practice Address - Country:US
Practice Address - Phone:216-299-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023653225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty