Provider Demographics
NPI:1508353210
Name:ROOTS SEEDS AND BRANCHES
Entity Type:Organization
Organization Name:ROOTS SEEDS AND BRANCHES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSUP PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-698-5553
Mailing Address - Street 1:209A SWANTON WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3271
Mailing Address - Country:US
Mailing Address - Phone:404-698-5553
Mailing Address - Fax:
Practice Address - Street 1:209A SWANTON WAY STE 202
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3271
Practice Address - Country:US
Practice Address - Phone:404-698-5553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0050181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181948CMedicaid