Basic Information
| Provider Information | |||||||||
| NPI: | 1386375665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEDIDAH | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | SYOMBUA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1024 E BROAD ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760637702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6825183333 | ||||||||
| FaxNumber: | 6825183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 E BROAD ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760637702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6825183323 | ||||||||
| FaxNumber: | 6825183323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2022 | ||||||||
| LastUpdateDate: | 06/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1059626 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.