=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497660211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2026
-----------------------------------------------------
Last Update Date | 08/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2583 GATEWAY DR STE 140
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-303-2005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2583 GATEWAY DR STE 140
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-303-2005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JADE MOORE STEPHENS
-----------------------------------------------------
Credential | LSW
-----------------------------------------------------
Telephone | 814-303-2005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------