Healthcare Provider Details

I. General information

NPI: 1609737790
Provider Name (Legal Business Name): EVERCARE SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 NW DIVISION ST
GRESHAM OR
97030-5350
US

IV. Provider business mailing address

1370 NW DIVISION ST
GRESHAM OR
97030-5350
US

V. Phone/Fax

Practice location:
  • Phone: 206-307-7941
  • Fax:
Mailing address:
  • Phone: 206-307-7941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIDUS JALELE
Title or Position: ADMINSTRATOR
Credential:
Phone: 206-307-7941