Provider Demographics
NPI:1720274061
Name:INGRAM, MICA JILL (AUD)
Entity Type:Individual
Prefix:DR
First Name:MICA
Middle Name:JILL
Last Name:INGRAM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W IH 635 FWY STE 360
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3764
Mailing Address - Country:US
Mailing Address - Phone:972-402-8404
Mailing Address - Fax:972-695-8796
Practice Address - Street 1:400 W IH 635 FWY STE 360
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3764
Practice Address - Country:US
Practice Address - Phone:972-402-8404
Practice Address - Fax:972-695-8796
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001032231H00000X
TX51740231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA211151001Medicaid