Provider Demographics
NPI:1902587124
Name:GRASSROOTS HEALING
Entity Type:Organization
Organization Name:GRASSROOTS HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-276-4334
Mailing Address - Street 1:10105 BALTIMORE AVE APT 3401
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4231
Mailing Address - Country:US
Mailing Address - Phone:410-937-1766
Mailing Address - Fax:
Practice Address - Street 1:10105 BALTIMORE AVE APT 3401
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-4231
Practice Address - Country:US
Practice Address - Phone:410-937-1766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty