Individual
JACKIE L. INGRAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMP
Contact information
Practice address
3912 MARTIN WAY E SUITE B, OLYMPIA, WA 98506
(360) 459-9780
(360) 412-0581
Mailing address
460 W BULB FARM RD, SHELTON, WA 98584-9154
(360) 490-6490
(360) 412-0581
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA00011670
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
125710
DEPT. OF LABOR & IND.
AL
01
—
IN7892
REGENCE BLUE SHIELD
WA
Enumeration date
10/26/2006
Last updated
07/21/2022
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