Healthcare Provider Details

I. General information

NPI: 1720117500
Provider Name (Legal Business Name): MRS. JULIE ANN ST. JOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JULIE ANN JEZERSKI

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 GENESSEE STREET
BOWMANSVILLE NY
14026-1044
US

IV. Provider business mailing address

1526 WALDEN AVENUE SUITE 400
CHEEKTOWAGA NY
14225-4985
US

V. Phone/Fax

Practice location:
  • Phone: 716-681-5077
  • Fax: 716-681-5079
Mailing address:
  • Phone: 716-895-7167
  • Fax: 716-332-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number077795-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: