Provider Demographics
NPI:1760046544
Name:GOSS, JACK WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WILLIAM
Last Name:GOSS
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 1:5600 METROPOLITAN PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4107
Mailing Address - Country:US
Mailing Address - Phone:586-264-2100
Mailing Address - Fax:
Practice Address - Street 1:5600 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4107
Practice Address - Country:US
Practice Address - Phone:586-264-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor