Provider Demographics
NPI:1609916477
Name:MCGOWEN, JACK (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MCGOWEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 YAGER LN
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-9718
Mailing Address - Country:US
Mailing Address - Phone:512-427-6273
Mailing Address - Fax:
Practice Address - Street 1:4841 YAGER LN
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-9718
Practice Address - Country:US
Practice Address - Phone:512-427-6273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9856111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R3490OtherBCBS PROVIDER NUMBER
TX11457838OtherCAQH NUMBER
TX8R3490OtherBCBS PROVIDER NUMBER
TX8D1518Medicare ID - Type UnspecifiedPROVIDER NUMBER