Provider Demographics
NPI:1336481803
Name:GERVAIS, JACQUALINE KAY (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:JACQUALINE
Middle Name:KAY
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MRS
Other - First Name:JACQUALINE
Other - Middle Name:
Other - Last Name:BLEESS TOPPEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:819. 30 AVE S OFFICE 206
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560
Mailing Address - Country:US
Mailing Address - Phone:218-233-2288
Mailing Address - Fax:
Practice Address - Street 1:819 30TH AVE S STE 206
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5054
Practice Address - Country:US
Practice Address - Phone:218-477-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR32567363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health