Provider Demographics
NPI:1265207567
Name:ROOTS FOUNDATIONAL COUNSELING LLC
Entity type:Organization
Organization Name:ROOTS FOUNDATIONAL COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:206-249-6133
Mailing Address - Street 1:9138 NE HOYT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5868
Mailing Address - Country:US
Mailing Address - Phone:206-249-6133
Mailing Address - Fax:
Practice Address - Street 1:9138 NE HOYT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-5868
Practice Address - Country:US
Practice Address - Phone:206-249-6133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty