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General NPI Number Information
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NPI Number | 1952106882
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Entity Type | Organization
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Legal Business Name | GRACEFUL WELLNESS LLC
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Dates
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Enumeration Date | 02/14/2025
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 2616 SOUTHERLAND ST STE 100
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City | JACKSON
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State | MS
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Zip | 39216-4855
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Country | US
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Telephone | 601-953-1504
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Fax | 601-866-1674
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Provider Business Mailing Address
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Address Line | 1783 JONES LOOP
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City | TERRY
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State | MS
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Zip | 39170-9013
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Country | US
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Telephone | 601-953-1504
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Fax | 601-866-1674
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DEIDRA THOMPSON
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Credential | PMHNP-BC
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Telephone | 601-953-1504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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