Provider Demographics
NPI:1265057376
Name:MCKENNIS, JOHNATHAN (CFSA)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:MCKENNIS
Suffix:
Gender:M
Credentials:CFSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850924
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0924
Mailing Address - Country:US
Mailing Address - Phone:601-214-4987
Mailing Address - Fax:
Practice Address - Street 1:1011 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2433
Practice Address - Country:US
Practice Address - Phone:214-320-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX176541207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics