Wild Earth Wellness

Primary specialty

Health Service Clinic/CenterTaxonomy code 261QH0100X

License

7615 Issued in OR

Legal business name

WILD EARTH WELLNESS

Practice address

24850 SE Stark St Ste 200
Gresham, OR 97030-8320

Phone

(503) 310-2622

NPI assigned

Aug 10, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Jennifer Marie Boom, LMT

Title

Owner

Phone

(503) 310-2622

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1502323200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1285159251",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24850 SE STARK ST STE 200",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970308320",
            "telephone_number": "503-310-2622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24850 SE STARK ST STE 200",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970308320",
            "telephone_number": "503-310-2622"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILD EARTH WELLNESS",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-08-10",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "BOOM",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "503-310-2622",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LMT"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "OR",
            "license": "7615",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1164547634",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Whiterose Care Homes LLC
• Rodney Whiteside
• Brooke Whiting, LE
• Grace Whitty, CSWA
• Emily Wiessner
• Jeb Riley Wild, DPT
• Jordan William Wilde, D.C.
• Tiffany Wildes
• Wildflower Counseling Collective LLC
• Jessica Ann Wilkerson, APRN-NP

• Health Service Clinic/Center in Gresham, OR
• Providers in Gresham, OR by specialty
• Health Service Clinic/Center in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.