Provider Demographics
NPI:1033147210
Name:HENNESSEE, JOHN PAUL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:HENNESSEE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 891868
Mailing Address - Street 2:SUITE A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73189-1868
Mailing Address - Country:US
Mailing Address - Phone:405-759-3880
Mailing Address - Fax:405-759-3882
Practice Address - Street 1:3224 SW 119TH ST STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4546
Practice Address - Country:US
Practice Address - Phone:405-759-3880
Practice Address - Fax:405-759-3882
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK184942084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090940AMedicaid
OK900522056OtherMEDICARE NUMBER
OK249231601Medicare ID - Type Unspecified
OK100090940AMedicaid