Provider Demographics
NPI:1417499286
Name:MCKENNA, JONATHON D (MA LPC)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:D
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1763 ST RT 60
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805
Mailing Address - Country:US
Mailing Address - Phone:419-289-4825
Mailing Address - Fax:419-289-4826
Practice Address - Street 1:1763 ST RT 60
Practice Address - Street 2:SUITE 120
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805
Practice Address - Country:US
Practice Address - Phone:419-289-4825
Practice Address - Fax:419-289-4826
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1500519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1073952271Medicaid