Provider Demographics
NPI:1184338824
Name:MIDWEST MENTAL HEALTH CLINIC PLLC
Entity type:Organization
Organization Name:MIDWEST MENTAL HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUALINE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GERVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-371-9769
Mailing Address - Street 1:819 30TH AVE S STE 206
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5054
Mailing Address - Country:US
Mailing Address - Phone:218-477-1353
Mailing Address - Fax:
Practice Address - Street 1:5306 BALLARD AVE NW STE 208
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4366
Practice Address - Country:US
Practice Address - Phone:206-607-9205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST MENTAL HEALTH CLINIC PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty