Healthcare Provider Details

I. General information

NPI: 1699551101
Provider Name (Legal Business Name): NOURISHED ROOTS THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 OLD US 1 HWY UNIT B
SOUTHERN PINES NC
28387-6308
US

IV. Provider business mailing address

1271 OLD US 1 HWY UNIT B
SOUTHERN PINES NC
28387-6308
US

V. Phone/Fax

Practice location:
  • Phone: 910-310-9479
  • Fax:
Mailing address:
  • Phone: 910-310-9479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENA LEIGH SOUTHERLAND
Title or Position: SPEECH- LANGUAGE PATHOLOGIST
Credential: MS, CCC-SLP, CLC
Phone: 910-310-9479