Healthcare Provider Details

I. General information

NPI: 1871316547
Provider Name (Legal Business Name): JAY EZRA GOLD LICSW, LADC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 OHMS LN STE 450
EDINA MN
55439-2339
US

IV. Provider business mailing address

7301 OHMS LN STE 450
EDINA MN
55439-2339
US

V. Phone/Fax

Practice location:
  • Phone: 612-605-8820
  • Fax:
Mailing address:
  • Phone: 612-605-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306430
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13202
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: