Healthcare Provider Details

I. General information

NPI: 1689338519
Provider Name (Legal Business Name): NORTHEASTERN HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 W KEETOOWAH ST
TAHLEQUAH OK
74464-3462
US

IV. Provider business mailing address

PO BOX 1008
TAHLEQUAH OK
74465-1008
US

V. Phone/Fax

Practice location:
  • Phone: 918-506-6901
  • Fax:
Mailing address:
  • Phone: 918-458-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JACKIE HULLINGER
Title or Position: VP OF REVENUE CYCLE
Credential:
Phone: 918-458-2417