Provider Demographics
NPI:1689301038
Name:INGRAM, JESSICA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SWISHER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-2322
Mailing Address - Country:US
Mailing Address - Phone:940-497-8455
Mailing Address - Fax:
Practice Address - Street 1:300 DOBBS RD
Practice Address - Street 2:
Practice Address - City:SHADY SHORES
Practice Address - State:TX
Practice Address - Zip Code:76208-5306
Practice Address - Country:US
Practice Address - Phone:940-497-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist