Provider Demographics
NPI:1114102787
Name:GOSS, JESSE C
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:C
Last Name:GOSS
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 1:6901 RIVER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8465
Mailing Address - Country:US
Mailing Address - Phone:817-732-0800
Mailing Address - Fax:817-596-5119
Practice Address - Street 1:1103 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5214
Practice Address - Country:US
Practice Address - Phone:254-771-5002
Practice Address - Fax:254-771-5008
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01313335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01313OtherTEXAS BOARD