Healthcare Provider Details

I. General information

NPI: 1184535239
Provider Name (Legal Business Name): ROOTS OF PURPOSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MILTON REID RD
DERIDDER LA
70634-8142
US

IV. Provider business mailing address

1401 LAVACA ST # 366
AUSTIN TX
78701-1634
US

V. Phone/Fax

Practice location:
  • Phone: 512-789-2833
  • Fax:
Mailing address:
  • Phone: 512-789-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KACEE KIETH JACKSON
Title or Position: CEO
Credential:
Phone: 512-789-2833