Provider Demographics
NPI:1720117500
Name:ST. JOHN, JULIE ANN
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:JEZERSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1526 WALDEN AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4985
Mailing Address - Country:US
Mailing Address - Phone:716-895-7167
Mailing Address - Fax:716-332-4488
Practice Address - Street 1:5360 GENESSEE STREET
Practice Address - Street 2:
Practice Address - City:BOWMANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14026-1044
Practice Address - Country:US
Practice Address - Phone:716-681-5077
Practice Address - Fax:716-681-5079
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077795-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical