=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417316902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE EARTH BAND OF OJIBWE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2016
-----------------------------------------------------
Last Update Date | 02/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2515 WORKFORCE CENTER ROAD
-----------------------------------------------------
City | MAHNOMEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-936-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70
-----------------------------------------------------
City | NAYTAHWAUSH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56566-0070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-936-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIORAL HEALTH DIRECTOR
-----------------------------------------------------
Name | JERI JASKEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-983-4647
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------