Provider Demographics
NPI:1790822237
Name:JOHNSTON, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1547
Practice Address - Country:US
Practice Address - Phone:888-975-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0701211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical