Provider Demographics
NPI:1578331971
Name:MIDWIFE GRACE, LLC
Entity type:Organization
Organization Name:MIDWIFE GRACE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:985-773-0449
Mailing Address - Street 1:340 BRAKEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3620
Mailing Address - Country:US
Mailing Address - Phone:985-265-4032
Mailing Address - Fax:985-202-4597
Practice Address - Street 1:340 BRAKEFIELD ST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3620
Practice Address - Country:US
Practice Address - Phone:985-265-4032
Practice Address - Fax:985-202-4597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-14
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty