Provider Demographics
NPI:1447357421
Name:GOETTSCH, JASON P (DC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:P
Last Name:GOETTSCH
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 1:4611 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8375
Mailing Address - Country:US
Mailing Address - Phone:925-754-8190
Mailing Address - Fax:925-706-7002
Practice Address - Street 1:4611 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8375
Practice Address - Country:US
Practice Address - Phone:925-754-8190
Practice Address - Fax:925-706-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U85015Medicare UPIN
CADC270710Medicare ID - Type Unspecified