Provider Demographics
NPI:1609443175
Name:GORDON, JESSE (LADC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELM ST APT 208
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4695
Mailing Address - Country:US
Mailing Address - Phone:917-750-3843
Mailing Address - Fax:
Practice Address - Street 1:APT FOUNDATION
Practice Address - Street 2:184 FRONT AVENUE
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001402101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)