Healthcare Provider Details

I. General information

NPI: 1205730843
Provider Name (Legal Business Name): ASSEFA JIMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6473 SE 31ST TER
GRESHAM OR
97080-8083
US

IV. Provider business mailing address

6473 SE 31ST TER
GRESHAM OR
97080-8083
US

V. Phone/Fax

Practice location:
  • Phone: 971-407-8280
  • Fax:
Mailing address:
  • Phone: 971-407-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: