Healthcare Provider Details

I. General information

NPI: 1265127708
Provider Name (Legal Business Name): JESSICA L KUDELA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3495 BAILEY AVE
BUFFALO NY
14215-1129
US

IV. Provider business mailing address

128 CAPE HATTERAS WALK
EAST AMHERST NY
14051-1083
US

V. Phone/Fax

Practice location:
  • Phone: 716-834-9200
  • Fax:
Mailing address:
  • Phone: 716-998-3247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number073342-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: