Provider Demographics
NPI:1831715176
Name:STRONG, DARNELL JACKIE (LICENSED CLINICAL)
Entity type:Individual
Prefix:MR
First Name:DARNELL
Middle Name:JACKIE
Last Name:STRONG
Suffix:
Gender:M
Credentials:LICENSED CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 NE HOLMAN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211
Mailing Address - Country:US
Mailing Address - Phone:503-309-2460
Mailing Address - Fax:503-477-7497
Practice Address - Street 1:435 NE 78TH AVE 'STRONG COUNSELING SERVICES'
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-309-2460
Practice Address - Fax:503-477-7497
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00007813104100000X
1041C0700X
ORL3548104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR517507Medicaid