Provider Demographics
NPI:1972814192
Name:HENNESSEE, JONATHAN J (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:J
Last Name:HENNESSEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 OWENSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20778
Mailing Address - Country:US
Mailing Address - Phone:410-867-4700
Mailing Address - Fax:410-867-8754
Practice Address - Street 1:134 OWENSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WEST RIVER
Practice Address - State:MD
Practice Address - Zip Code:20778
Practice Address - Country:US
Practice Address - Phone:410-867-4700
Practice Address - Fax:410-867-8754
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHRT-2118207Q00000X
MDH76407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404482700Medicaid
MD211840Medicare PIN