Healthcare Provider Details

I. General information

NPI: 1407637895
Provider Name (Legal Business Name): JESSE SAMUEL GOLDBLUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 01/04/2025
Certification Date: 01/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 ALBANY AVE
HARTFORD CT
06105-1001
US

IV. Provider business mailing address

55 MARVEL RD APT B2
NEW HAVEN CT
06515-2169
US

V. Phone/Fax

Practice location:
  • Phone: 860-297-0520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13775
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number196780
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: