Healthcare Provider Details

I. General information

NPI: 1205474681
Provider Name (Legal Business Name): JERICHO ROAD MINISTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E TUPPER ST
BUFFALO NY
14203-1315
US

IV. Provider business mailing address

100 E TUPPER ST
BUFFALO NY
14203-1315
US

V. Phone/Fax

Practice location:
  • Phone: 716-881-6191
  • Fax:
Mailing address:
  • Phone: 716-919-6870
  • Fax: 716-919-6871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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