NPIMap

Organization Active NPI

Midwest Mental Health Clinic PLLC

Doing business as Midwest Mental Health

  • Addiction (Substance Use Disorder) Counselor
  • Fargo, ND
National Provider Identifier
1710600028
Registry record updated Jun 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X
Legal business name
MIDWEST MENTAL HEALTH CLINIC PLLC
Doing business as
Midwest Mental Health
Practice address
121 University Dr N
Fargo, ND 58102-4631
Phone
(701) 478-5808
NPI assigned
Sep 21, 2022
Last updated
Jun 27, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
MIDWEST MENTAL HEALTH CLINIC PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 27, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jacqualine Kay Gervais, DNP, PMHNP, CARN-APNPI 1336481803
Title
President/Owner
Phone
(701) 371-9769

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X Primary

Addresses

Primary practice location

121 University Dr N
Fargo, ND 58102-4631

Mailing address

1122 1St Ave N
Fargo, ND 58102-4604

Other practice location 1

333 19th St N
Fargo, ND 58102-4145
Phone (701) 478-5808

Other names 1

  • Midwest Mental Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220711002159 ND Part B Supplier - Clinic/Group Practice 6204216070 Receives reassigned benefits from 7 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fargo, ND

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Midwest Mental Health Clinic PLLC2 organizations share this tax ID, including this one
Part of
Midwest Mental Health Clinic PLLC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1122 1st Ave N
Fargo, ND 58102
Phone (218) 477-1353

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1663718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719446400000",
    "number": "1710600028",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1122 1ST AVE N",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581024604"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "121 UNIVERSITY DR N",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581024631",
            "telephone_number": "701-478-5808"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "333 19th St N",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "581024145",
            "country_code": "US",
            "telephone_number": "701-478-5808",
            "fax_number": "218-477-1354",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MIDWEST MENTAL HEALTH CLINIC PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MIDWEST MENTAL HEALTH CLINIC PLLC",
        "enumeration_date": "2022-09-21",
        "last_updated": "2024-06-27",
        "certification_date": "2024-06-27",
        "status": "A",
        "authorized_official_last_name": "GERVAIS",
        "authorized_official_first_name": "JACQUALINE",
        "authorized_official_middle_name": "KAY",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "701-371-9769",
        "authorized_official_credential": "DNP, PMHNP, CARN-AP"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Midwest Mental Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Midwest Mental Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fargo, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.