Healthcare Provider Details

I. General information

NPI: 1952229130
Provider Name (Legal Business Name): SUNROOT PSYCHIATRIC WELLNESS, A PROFESSIONAL NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12307 WILLOW RD
LAKESIDE CA
92040-1426
US

IV. Provider business mailing address

2108 N ST STE N
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 619-792-0513
  • Fax:
Mailing address:
  • Phone: 619-792-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNA MARIE FAZIO
Title or Position: CEO
Credential:
Phone: 619-792-0513