Healthcare Provider Details

I. General information

NPI: 1457639551
Provider Name (Legal Business Name): WHITE EARTH BAND OF OJIBWE - INDIAN CHILD WELFARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FEATHER STREET
OGEMA MN
56569
US

IV. Provider business mailing address

301 FEATHER STREET
OGEMA MN
56569
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-3011
  • Fax: 218-983-3002
Mailing address:
  • Phone: 218-983-3011
  • Fax: 218-983-3002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0086
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14486
License Number StateMN

VIII. Authorized Official

Name: JERI LYNN JASKEN
Title or Position: CHILD WELFARE DIRECTOR
Credential:
Phone: 218-983-4647