Provider Demographics
NPI:1912447434
Name:OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH
Entity Type:Organization
Organization Name:OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, ARNP
Authorized Official - Phone:253-509-2960
Mailing Address - Street 1:6002 WESTGATE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2570
Mailing Address - Country:US
Mailing Address - Phone:253-509-2960
Mailing Address - Fax:253-292-1045
Practice Address - Street 1:6002 WESTGATE BLVD
Practice Address - Street 2:SUITES 270 & 274
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2570
Practice Address - Country:US
Practice Address - Phone:253-509-2960
Practice Address - Fax:253-292-1045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003731367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12013042OtherCAQH
1780661694OtherNPPES
WA9620246Medicaid