Healthcare Provider Details

I. General information

NPI: 1619307022
Provider Name (Legal Business Name): JERICHO ROAD MINISTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 09/09/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DOAT STREET
BUFFALO NY
14211-1612
US

IV. Provider business mailing address

21 DOAT STREET
BUFFALO NY
14211-1616
US

V. Phone/Fax

Practice location:
  • Phone: 716-892-2775
  • Fax: 716-597-0554
Mailing address:
  • Phone: 716-892-2775
  • Fax: 716-597-0554

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