Provider Demographics
NPI:1154497097
Name:JENEN, JOHN RICHARD (DPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:JENEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 E.74 TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-488-8166
Mailing Address - Fax:918-493-2990
Practice Address - Street 1:6666 S SHERIDAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1756
Practice Address - Country:US
Practice Address - Phone:918-493-2727
Practice Address - Fax:918-493-2990
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist