Provider Demographics
NPI:1255512851
Name:GOSWICK, JACK L (MS)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:GOSWICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 ROTAN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4007
Mailing Address - Country:US
Mailing Address - Phone:512-777-9774
Mailing Address - Fax:
Practice Address - Street 1:3355 BEE CAVE RD
Practice Address - Street 2:BUILDING 1 SUITE 104
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6775
Practice Address - Country:US
Practice Address - Phone:512-777-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-25
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201403106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist