Healthcare Provider Details

I. General information

NPI: 1124949342
Provider Name (Legal Business Name): GRACE PROVIDER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TIGER BEND RD
KENTWOOD LA
70444-8131
US

IV. Provider business mailing address

365 TIGER BEND RD
KENTWOOD LA
70444-8131
US

V. Phone/Fax

Practice location:
  • Phone: 601-310-9340
  • Fax:
Mailing address:
  • Phone: 601-310-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MICHELLE HASTY
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 601-310-9340