Provider Demographics
NPI:1316488117
Name:INGRAM, LAKISHA T (BA)
Entity type:Individual
Prefix:MRS
First Name:LAKISHA
Middle Name:T
Last Name:INGRAM
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 GREENCASTLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3834
Mailing Address - Country:US
Mailing Address - Phone:731-614-3572
Mailing Address - Fax:731-668-0380
Practice Address - Street 1:168 GREENCASTLE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-614-3572
Practice Address - Fax:731-668-0340
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)