Healthcare Provider Details

I. General information

NPI: 1265057376
Provider Name (Legal Business Name): JOHNATHAN MCKENNIS CFSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N GALLOWAY AVE
MESQUITE TX
75149-2433
US

IV. Provider business mailing address

PO BOX 850924
MESQUITE TX
75185-0924
US

V. Phone/Fax

Practice location:
  • Phone: 214-320-7000
  • Fax:
Mailing address:
  • Phone: 601-214-4987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number176541
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number176541
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: