Healthcare Provider Details

I. General information

NPI: 1104571322
Provider Name (Legal Business Name): JESIKA FORSYTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 N MAIN ST
WARSAW NY
14569-1326
US

IV. Provider business mailing address

227 THORN AVE
ORCHARD PARK NY
14127-2600
US

V. Phone/Fax

Practice location:
  • Phone: 585-786-0220
  • Fax: 585-783-3631
Mailing address:
  • Phone: 716-539-6737
  • Fax: 716-662-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: