=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184338824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST MENTAL HEALTH CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2023
-----------------------------------------------------
Last Update Date | 01/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5306 BALLARD AVE NW STE 208
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98107-4366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-607-9205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 30TH AVE S STE 206
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-477-1353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUALINE KAY GERVAIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-371-9769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------