Provider Demographics
NPI:1750707006
Name:MANUELE, JACK D (DC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:MANUELE
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 1:1930 W GLENOAKS BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1647
Mailing Address - Country:US
Mailing Address - Phone:818-842-4444
Mailing Address - Fax:
Practice Address - Street 1:1930 W GLENOAKS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1647
Practice Address - Country:US
Practice Address - Phone:818-842-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor