Healthcare Provider Details

I. General information

NPI: 1417864778
Provider Name (Legal Business Name): HEALTHY ROOTS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21101 NE CEDAR CREEK RD
AMBOY WA
98601-3802
US

IV. Provider business mailing address

PO BOX 340
BATTLE GROUND WA
98604-0340
US

V. Phone/Fax

Practice location:
  • Phone: 303-815-7346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name: ANAHEED JACKSON
Title or Position: OWNER
Credential: ND
Phone: 303-815-7346