Provider Demographics
NPI:1427093475
Name:GERVAIS, JONATHAN PAUL (AUD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PAUL
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803
Mailing Address - Country:US
Mailing Address - Phone:218-724-5027
Mailing Address - Fax:
Practice Address - Street 1:2015 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-2414
Practice Address - Country:US
Practice Address - Phone:218-724-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6443231H00000X
WI332156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN443928700Medicaid
MN443928700Medicaid