Provider Demographics
NPI:1891776829
Name:PETTIS-INGRAM, JANICE M (EDD, LLC)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:PETTIS-INGRAM
Suffix:
Gender:F
Credentials:EDD, LLC
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:PETTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD
Mailing Address - Street 1:5201 S WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-1622
Mailing Address - Country:US
Mailing Address - Phone:214-339-2047
Mailing Address - Fax:214-339-2049
Practice Address - Street 1:5201 S WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-1622
Practice Address - Country:US
Practice Address - Phone:214-339-2047
Practice Address - Fax:214-339-2049
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10714101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82462LMedicare ID - Type Unspecified
TXB0057313Medicare UPIN