Healthcare Provider Details

I. General information

NPI: 1801424346
Provider Name (Legal Business Name): JACK MANQUEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 S HARVARD AVE
TULSA OK
74112-6826
US

IV. Provider business mailing address

1706 S CEDAR AVE
BROKEN ARROW OK
74012-6407
US

V. Phone/Fax

Practice location:
  • Phone: 405-730-6990
  • Fax: 405-730-6992
Mailing address:
  • Phone: 586-214-8344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7329
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number010269
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: