Healthcare Provider Details

I. General information

NPI: 1235720665
Provider Name (Legal Business Name): JORDAN L GOLDBERG LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 HAZARD AVE
ENFIELD CT
06082-4592
US

IV. Provider business mailing address

2 WATERSIDE XING STE 401
WINDSOR CT
06095-1588
US

V. Phone/Fax

Practice location:
  • Phone: 860-253-5020
  • Fax: 860-731-5536
Mailing address:
  • Phone: 860-731-5522
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1651
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: