Provider Demographics
NPI:1912566886
Name:JACKSON, GRACE (CPM LM)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPM LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 BROWN THRASHER LOOP S
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3035
Mailing Address - Country:US
Mailing Address - Phone:985-773-0449
Mailing Address - Fax:
Practice Address - Street 1:397 BROWN THRASHER LOOP S
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-3035
Practice Address - Country:US
Practice Address - Phone:985-773-0449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312612176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife