Provider Demographics
NPI:1306551122
Name:INGRAM, JAIME
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25062 S 190TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5668
Mailing Address - Country:US
Mailing Address - Phone:480-329-0707
Mailing Address - Fax:
Practice Address - Street 1:25062 S 190TH ST
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5668
Practice Address - Country:US
Practice Address - Phone:480-329-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171400000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171400000XOther Service ProvidersHealth & Wellness Coach