Provider Demographics
NPI:1912969544
Name:GERVAIS, JENNIFER LANE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LANE
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 CURRELL BLVD
Mailing Address - Street 2:SUITE 275
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2290
Mailing Address - Country:US
Mailing Address - Phone:612-859-9405
Mailing Address - Fax:
Practice Address - Street 1:7616 CURRELL BLVD
Practice Address - Street 2:SUITE 275
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2290
Practice Address - Country:US
Practice Address - Phone:612-859-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
136608400OtherCADI
MN136608400Medicaid