Provider Demographics
NPI:1407877277
Name:GOURLIE, JAY THOMAS
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:THOMAS
Last Name:GOURLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-9600
Mailing Address - Country:US
Mailing Address - Phone:651-645-2227
Mailing Address - Fax:
Practice Address - Street 1:2221 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1800
Practice Address - Country:US
Practice Address - Phone:651-645-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69260GOOtherBCBS
MN6107401OtherUBH MEDICA