Provider Demographics
NPI:1487690715
Name:INGERSOLL, JAMES W (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:INGERSOLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JAMESW
Other - Middle Name:W
Other - Last Name:INGERSOLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1115 OLYMPIA AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-943-2555
Mailing Address - Fax:
Practice Address - Street 1:1115 OLYMPIA AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-943-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA446103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR31749Medicare UPIN
WA001002544Medicare ID - Type Unspecified