Provider Demographics
NPI:1730376542
Name:GOSS, JERRY WILLIS (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WILLIS
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 1:1498 SANS SOUCI PKWY
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-6026
Mailing Address - Country:US
Mailing Address - Phone:570-829-5888
Mailing Address - Fax:570-970-2757
Practice Address - Street 1:1498 SANS SOUCI PKWY
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-6026
Practice Address - Country:US
Practice Address - Phone:570-829-5888
Practice Address - Fax:570-970-2757
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-5357 L111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01678207OtherHIGHMARK
G0127263OtherFIRST PRIORITY
5566734OtherAETNA
PA0014723000002Medicaid
800211OtherBLUE CROSS
800211OtherBLUE CROSS