Provider Demographics
NPI:1497893739
Name:TRUSSELL, JACKIE SIEGEL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:SIEGEL
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 ROBINWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1302
Mailing Address - Country:US
Mailing Address - Phone:503-699-1093
Mailing Address - Fax:
Practice Address - Street 1:14815 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2336
Practice Address - Country:US
Practice Address - Phone:503-761-7139
Practice Address - Fax:503-761-7917
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL27491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical