Provider Demographics
NPI:1881124261
Name:MCKINNEY, JESSE MIKE (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:MIKE
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 MENCHACA RD APT 208
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 S COLORADO ST STE 110
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-3906
Practice Address - Country:US
Practice Address - Phone:512-213-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX331431223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice