Healthcare Provider Details

I. General information

NPI: 1609702604
Provider Name (Legal Business Name): GROUNDED WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W WASHINGTON ST
BOISE ID
83702-5446
US

IV. Provider business mailing address

141 N PALMETTO AVE UNIT 1241
EAGLE ID
83616-8050
US

V. Phone/Fax

Practice location:
  • Phone: 208-860-2390
  • Fax:
Mailing address:
  • Phone: 208-860-2390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JACKELLE KNICKREHM
Title or Position: OWNER
Credential:
Phone: 208-860-2390