Healthcare Provider Details

I. General information

NPI: 1972944080
Provider Name (Legal Business Name): JERICHO ROAD MINISTRIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 BARTON ST
BUFFALO NY
14213
US

IV. Provider business mailing address

184 BARTON ST
BUFFALO NY
14213-1573
US

V. Phone/Fax

Practice location:
  • Phone: 716-881-6191
  • Fax: 716-881-6247
Mailing address:
  • Phone: 716-881-6191
  • Fax: 716-881-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JACKIE ENDRESS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 716-348-3000