Provider Demographics
NPI:1083592000
Name:INGRAM, KIMBERLY JEAN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-5738
Mailing Address - Country:US
Mailing Address - Phone:515-300-0054
Mailing Address - Fax:
Practice Address - Street 1:5415 NW 88TH ST STE 100
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-2951
Practice Address - Country:US
Practice Address - Phone:515-727-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health