Provider Demographics
NPI:1568117679
Name:SUSTAINED ROOTS
Entity Type:Organization
Organization Name:SUSTAINED ROOTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN, CDCES
Authorized Official - Phone:619-866-8084
Mailing Address - Street 1:1208 NW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-3686
Mailing Address - Country:US
Mailing Address - Phone:816-226-6605
Mailing Address - Fax:
Practice Address - Street 1:1208 NW 112TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-3686
Practice Address - Country:US
Practice Address - Phone:816-226-6605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty