Provider Demographics
NPI:1710600028
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:PRESIDENT/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:DNP, PMHNP, CARN-AP
Authorized Official - Phone:701-371-9769
Mailing Address - Street 1:1122 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 4TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4233
Practice Address - Country:US
Practice Address - Phone:701-478-5808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST MENTAL HEALTH CLINIC PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty