Healthcare Provider Details

I. General information

NPI: 1740513969
Provider Name (Legal Business Name): JESSICA L. BOSARGE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 E MAIN ST STE 2
BATAVIA NY
14020-3444
US

IV. Provider business mailing address

3020 BAILEY AVE
BUFFALO NY
14215-2814
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-1421
  • Fax: 585-344-3047
Mailing address:
  • Phone: 716-831-0200
  • Fax: 716-831-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080880-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number080880-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: