1184157000 NPI number — MRS. JESSICA MAE RUNKLE MS

Table of content: MRS. JESSICA MAE RUNKLE MS (NPI 1184157000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184157000 NPI number — MRS. JESSICA MAE RUNKLE MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNKLE
Provider First Name:
JESSICA
Provider Middle Name:
MAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
JESSICA
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184157000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21636-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-634-2380
Provider Business Mailing Address Fax Number:
833-908-2287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21636-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-634-2380
Provider Business Practice Location Address Fax Number:
833-908-2287
Provider Enumeration Date:
04/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LC10729 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LC10729 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LC10729 . This is a "PROFESSIONAL CLINICAL MENTAL HEALTH COUNSELOR" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 609550002 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 609550005 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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