NPIMap

Organization Active NPI

Midwest Mental Health Clinic PLLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Fargo, ND
National Provider Identifier
1861877052
Registry record updated Jan 17, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
License
CNP3899 Issued in MN
Legal business name
MIDWEST MENTAL HEALTH CLINIC PLLC
Practice address
1122 1St Ave N
Fargo, ND 58102-4604
Phone
(218) 477-1353
Fax
(218) 477-1354
NPI assigned
Jul 29, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 17, 2023

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

Authorized official

Name
Jacqualine Gervais, PMHNPNPI 1336481803
Title
Owner
Phone
(218) 477-1353

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
Psychiatric/Mental Health Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP0808X CNP3899 MN Primary

Addresses

Primary practice location

1122 1St Ave N
Fargo, ND 58102-4604

Mailing address

819 30TH Ave S Office 206 Suite B
Moorhead, MN 56560
Phone (218) 477-1353

Other practice location 1

819 30th Ave S Office 206 Suite B
Moorhead, MN 56560
Phone (218) 477-1353

Other practice location 2

5306 Ballard Ave NW Ste 208
Seattle, WA 98107-4366
Phone (218) 477-1353

Other practice location 3

1829 S Broadway Ste 4
Minot, ND 58701-6571
Phone (218) 477-1353

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND, MN2 enrollments

Enrollment records 2

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
Practice locations: Fargo, ND
O20230831004639 MN Part B Supplier - Clinic/Group Practice 6204216070 Receives reassigned benefits from 6 practitioners
Practice locations: Moorhead, MN

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

Locations

819 30th Ave S
Ste 206B
Moorhead, MN 56560
Phone (218) 477-1353

819 30th Ave S
Ste 206
Moorhead, MN 56560
Phone (218) 477-1353

121 University Dr N
Fargo, ND 58102
Phone (218) 477-1353

1829 S Broadway
Ste 4
Minot, ND 58701
Phone (218) 477-1353

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 21

NPI Registry JSON

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

{
    "created_epoch": "1438128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1673913600000",
    "number": "1861877052",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "819 30TH AVE S OFFICE 206 SUITE B",
            "city": "MOORHEAD",
            "state": "MN",
            "postal_code": "56560",
            "telephone_number": "218-477-1353",
            "fax_number": "218-477-1354"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1122 1ST AVE N",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581024604",
            "telephone_number": "218-477-1353",
            "fax_number": "218-477-1354"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "819 30th Ave S Office 206 Suite B",
            "address_purpose": "LOCATION",
            "city": "Moorhead",
            "state": "MN",
            "postal_code": "56560",
            "country_code": "US",
            "telephone_number": "218-477-1353",
            "fax_number": "218-477-1354",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "5306 Ballard Ave NW Ste 208",
            "address_purpose": "LOCATION",
            "city": "Seattle",
            "state": "WA",
            "postal_code": "981074366",
            "country_code": "US",
            "telephone_number": "218-477-1353",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1829 S Broadway Ste 4",
            "address_purpose": "LOCATION",
            "city": "Minot",
            "state": "ND",
            "postal_code": "587016571",
            "country_code": "US",
            "telephone_number": "218-477-1353",
            "fax_number": "218-477-1354",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MIDWEST MENTAL HEALTH CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-29",
        "last_updated": "2023-01-17",
        "certification_date": "2023-01-17",
        "status": "A",
        "authorized_official_last_name": "GERVAIS",
        "authorized_official_first_name": "JACQUALINE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "218-477-1353",
        "authorized_official_credential": "PMHNP"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "MN",
            "license": "CNP3899",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Jan 17, 2023; 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.