MEDICARE: WHITE EARTH BAND OF OJIBWE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053772046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE EARTH BAND OF OJIBWE

Provider Business Mailing Address
First Line	:	1730 CLIFTON PL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3242
Country	:	US
Telephone Number	:	763-464-4137
Fax Number	:

Provider Business Practice Location Address
First Line	:	1730 CLIFTON PL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3242
Country	:	US
Telephone Number	:	763-464-4137
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIORAL HEALTH DIRECTOR
Name	:	JERI JASKEN
Credential	:
Telephone Number	:	218-983-4647

Provider Enumeration Date	:	03/17/2016
Last Update Date	:	03/17/2016

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