Provider Demographics
NPI:1952742017
Name:GONSOWSKI, JEREMY (DC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GONSOWSKI
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:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-0593
Mailing Address - Country:US
Mailing Address - Phone:606-878-0088
Mailing Address - Fax:
Practice Address - Street 1:1750 HIGHWAY 192 W
Practice Address - Street 2:SUITE 4
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2639
Practice Address - Country:US
Practice Address - Phone:606-878-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor