Provider Demographics
NPI:1285418517
Name:BLKJADE. MENTAL WELLNESS, LLC.
Entity type:Organization
Organization Name:BLKJADE. MENTAL WELLNESS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:SHEENA
Authorized Official - Last Name:CAPPARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CADC-R
Authorized Official - Phone:503-208-8258
Mailing Address - Street 1:3519 NE 15TH AVE # 294
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2356
Mailing Address - Country:US
Mailing Address - Phone:503-208-8258
Mailing Address - Fax:
Practice Address - Street 1:2926 NE FLANDERS ST # 3A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3259
Practice Address - Country:US
Practice Address - Phone:503-208-8258
Practice Address - Fax:503-328-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-18
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1861893232Medicaid
OR500822543Medicaid