Healthcare Provider Details

I. General information

NPI: 1215502711
Provider Name (Legal Business Name): JERICHO ROAD MINISTRIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 BRECKENRIDGE ST
BUFFALO NY
14213-1562
US

IV. Provider business mailing address

182 BRECKENRIDGE ST
BUFFALO NY
14213-1562
US

V. Phone/Fax

Practice location:
  • Phone: 716-348-3025
  • Fax: 716-348-3011
Mailing address:
  • Phone: 716-348-3011
  • Fax: 716-348-3025

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