Individual
JACK INGRAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1500 S MAIN ST, FT WORTH, TX 76104-4917
(817) 702-3431
Mailing address
1500 S MAIN ST, FT WORTH, TX 76104-4917
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
BP10055948
TX
Other
Enumeration date
08/15/2016
Last updated
08/15/2016
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