Provider Demographics
NPI:1669580783
Name:INGRHAM, JODIE
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:INGRHAM
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 1:8430 BIG BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3116
Mailing Address - Country:US
Mailing Address - Phone:314-963-1343
Mailing Address - Fax:
Practice Address - Street 1:32 HAMPTON VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2127
Practice Address - Country:US
Practice Address - Phone:314-353-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002008836OtherLICENSE#