Healthcare Provider Details

I. General information

NPI: 1508777178
Provider Name (Legal Business Name): GRACE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MARKET ST NE STE 426
SALEM OR
97301-1894
US

IV. Provider business mailing address

3000 MARKET ST NE STE 426
SALEM OR
97301-1894
US

V. Phone/Fax

Practice location:
  • Phone: 503-583-3604
  • Fax:
Mailing address:
  • Phone: 503-583-3604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. GERARDO JIMENEZ
Title or Position: LCSW
Credential: MSW
Phone: 503-583-3604