Provider Demographics
NPI:1952893091
Name:JERICHO ROAD MINISTRIES, INC.
Entity Type:Organization
Organization Name:JERICHO ROAD MINISTRIES, INC.
Other - Org Name:JERICHO ROAD COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-348-3000
Mailing Address - Street 1:184 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1573
Mailing Address - Country:US
Mailing Address - Phone:716-881-6191
Mailing Address - Fax:716-881-6247
Practice Address - Street 1:1021 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14212-1460
Practice Address - Country:US
Practice Address - Phone:716-529-3020
Practice Address - Fax:716-529-3040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JERICHO ROAD MINISTRIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-05
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1401237R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)