Healthcare Provider Details

I. General information

NPI: 1689503500
Provider Name (Legal Business Name): WILD ROOTS BIRTH COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1164A E GANNON DR
FESTUS MO
63028-2604
US

IV. Provider business mailing address

14268 SPRING DR
DE SOTO MO
63020-5146
US

V. Phone/Fax

Practice location:
  • Phone: 573-944-1832
  • Fax:
Mailing address:
  • Phone: 573-944-1832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: JACQUELYNE LIVENGOOD
Title or Position: CEO
Credential: CD
Phone: 573-944-1832