Healthcare Provider Details

I. General information

NPI: 1497660211
Provider Name (Legal Business Name): EVERGREEN WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2583 GATEWAY DR STE 140
STATE COLLEGE PA
16801-3098
US

IV. Provider business mailing address

2583 GATEWAY DR STE 140
STATE COLLEGE PA
16801-3098
US

V. Phone/Fax

Practice location:
  • Phone: 814-303-2005
  • Fax:
Mailing address:
  • Phone: 814-303-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JADE MOORE STEPHENS
Title or Position: OWNER
Credential: LSW
Phone: 814-303-2005