Provider Demographics
NPI:1609832914
Name:ERICKSON, JENNIFER N (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:N
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3671 SOUTHWESTERN BLVD ST 213
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-7008
Mailing Address - Fax:716-662-5226
Practice Address - Street 1:3671 SOUTHWESTERN BLVD ST 213
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-662-7008
Practice Address - Fax:716-662-5226
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC4903Medicare ID - Type Unspecified
AA0792Medicare ID - Type UnspecifiedGROUP
E42077Medicare UPIN