Healthcare Provider Details

I. General information

NPI: 1548999766
Provider Name (Legal Business Name): JACOB SCOTT GERVAIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 N 7TH ST STE 405
PHOENIX AZ
85006-2754
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-3151
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9864
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: