Provider Demographics
NPI:1710649207
Name:GOLD, JONATHAN STEVEN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:STEVEN
Last Name:GOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 NORTH AVE APT 8W
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2411
Mailing Address - Country:US
Mailing Address - Phone:201-638-1783
Mailing Address - Fax:
Practice Address - Street 1:555 NORTH AVE APT 8W
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2411
Practice Address - Country:US
Practice Address - Phone:201-638-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001764-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health