Healthcare Provider Details

I. General information

NPI: 1346604246
Provider Name (Legal Business Name): WHITE EARTH BAND OF OJIBWE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 310TH AVE
NAYTAHWAUSH MN
56566-9998
US

IV. Provider business mailing address

2531 310TH AVE
NAYTAHWAUSH MN
56566-9998
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-3285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JERI JASKEN
Title or Position: BEHAVIORAL HEALTH DIRECTOR
Credential:
Phone: 218-983-4647