Healthcare Provider Details

I. General information

NPI: 1912447434
Provider Name (Legal Business Name): OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 WESTGATE BLVD SUITES 270 & 274
TACOMA WA
98406-2570
US

IV. Provider business mailing address

6002 WESTGATE BLVD SUITE 120
TACOMA WA
98406-2570
US

V. Phone/Fax

Practice location:
  • Phone: 253-509-2960
  • Fax: 253-292-1045
Mailing address:
  • Phone: 253-509-2960
  • Fax: 253-292-1045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP30003731
License Number StateWA

VIII. Authorized Official

Name: MRS. KATHRYN B JACKSON
Title or Position: OWNER, ADMINISTRATOR
Credential: CNM, ARNP
Phone: 253-509-2960