Provider Demographics
NPI:1104432293
Name:INGHAM, JACQUELINE FAITH
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:FAITH
Last Name:INGHAM
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 1:1130 TEN ROD RD STE F101
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4170
Mailing Address - Country:US
Mailing Address - Phone:401-295-2955
Mailing Address - Fax:
Practice Address - Street 1:1130 TEN ROD RD STE F101
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4170
Practice Address - Country:US
Practice Address - Phone:401-295-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT01620225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics