Basic Information
| Provider Information | |||||||||
| NPI: | 1720117500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST. JOHN | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JEZERSKI | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1526 WALDEN AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168957167 | ||||||||
| FaxNumber: | 7163324488 | ||||||||
| Practice Location | |||||||||
| Address1: | 5360 GENESSEE STREET | ||||||||
| Address2: | |||||||||
| City: | BOWMANSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140261044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166815077 | ||||||||
| FaxNumber: | 7166815079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 077795-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.