Provider Demographics
NPI:1376628248
Name:INGRAM, JACKIE L (LMP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 W BULB FARM RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-9154
Mailing Address - Country:US
Mailing Address - Phone:360-490-6490
Mailing Address - Fax:360-412-0581
Practice Address - Street 1:3912 MARTIN WAY E SUITE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-459-9780
Practice Address - Fax:360-412-0581
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAIN7892OtherREGENCE BLUE SHIELD
AL125710OtherDEPT. OF LABOR & IND.