Healthcare Provider Details

I. General information

NPI: 1649100991
Provider Name (Legal Business Name): GRACE CARRIES WELLNESS COLLABORATIVE AND CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9565 SYLVAN STILL RD APT Q
LAUREL MD
20723-1540
US

IV. Provider business mailing address

9565 SYLVAN STILL RD APT Q
LAUREL MD
20723-1540
US

V. Phone/Fax

Practice location:
  • Phone: 443-537-9626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN JACKSON
Title or Position: LEAD CLINICAN
Credential: LCPC
Phone: 240-354-7446