Provider Demographics
NPI:1780055996
Name:LAFOSSE, JACK (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LAFOSSE
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 1:1374 RICHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4947
Mailing Address - Country:US
Mailing Address - Phone:631-804-9995
Mailing Address - Fax:
Practice Address - Street 1:1374 RICHLAND BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4947
Practice Address - Country:US
Practice Address - Phone:631-804-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009251111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor