Healthcare Provider Details

I. General information

NPI: 1578331971
Provider Name (Legal Business Name): MIDWIFE GRACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BRAKEFIELD ST
SLIDELL LA
70458-3620
US

IV. Provider business mailing address

340 BRAKEFIELD ST
SLIDELL LA
70458-3620
US

V. Phone/Fax

Practice location:
  • Phone: 985-265-4032
  • Fax: 985-202-4597
Mailing address:
  • Phone: 985-265-4032
  • Fax: 985-202-4597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNULL

VIII. Authorized Official

Name: GRACE JACKSON
Title or Position: CLINICAL DIRECTOR/OWNER
Credential: CPM
Phone: 985-773-0449