Healthcare Provider Details

I. General information

NPI: 1609594431
Provider Name (Legal Business Name): GRASSROOTS HEALTH A SOCIAL PURPOSE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 DOBBINS ST STE A
VACAVILLE CA
95688-2700
US

IV. Provider business mailing address

97 DOBBINS ST STE A
VACAVILLE CA
95688-2700
US

V. Phone/Fax

Practice location:
  • Phone: 707-887-3651
  • Fax: 707-210-0480
Mailing address:
  • Phone: 707-887-3651
  • Fax: 707-210-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JERRY MICHAEL CLINE
Title or Position: PHYSICIAN
Credential: MD
Phone: 707-887-3651