Healthcare Provider Details

I. General information

NPI: 1659294668
Provider Name (Legal Business Name): JORDAN CHARLES COLUCCI I LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 FOXSHIRE DR
LANCASTER PA
17601-3982
US

IV. Provider business mailing address

120 FOXSHIRE DR
LANCASTER PA
17601-3982
US

V. Phone/Fax

Practice location:
  • Phone: 717-431-6615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: