Provider Demographics
NPI:1659064293
Name:OLD GROWTH HEALING LLC
Entity Type:Organization
Organization Name:OLD GROWTH HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-457-3469
Mailing Address - Street 1:220 DIVISION ST S
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2046
Mailing Address - Country:US
Mailing Address - Phone:952-457-3469
Mailing Address - Fax:
Practice Address - Street 1:220 DIVISION ST S STE 2
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2046
Practice Address - Country:US
Practice Address - Phone:952-457-3469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty