Provider Demographics
NPI:1326195256
Name:JARVIS, MARY ELIZABETH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:JARVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:JARVIS-PRIBNOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:1821 UNIVERSITY AVE W STE N187
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2814
Mailing Address - Country:US
Mailing Address - Phone:651-603-9540
Mailing Address - Fax:651-603-9543
Practice Address - Street 1:1821 UNIVERSITY AVE W STE N187
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2814
Practice Address - Country:US
Practice Address - Phone:651-603-9540
Practice Address - Fax:651-603-9543
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN66281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN442899400Medicaid