Basic Information
Provider Information | |||||||||
NPI: | 1184157000 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUNKLE | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | MAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILLIAMS | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | MAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 316 RAILROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | MD | ||||||||
PostalCode: | 216361126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106342380 | ||||||||
FaxNumber: | 8339082287 | ||||||||
Practice Location | |||||||||
Address1: | 316 RAILROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | MD | ||||||||
PostalCode: | 216361126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106342380 | ||||||||
FaxNumber: | 8339082287 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2017 | ||||||||
LastUpdateDate: | 09/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC10729 | MD | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 609550002 | 05 | MD |   | MEDICAID | LC10729 | 01 | MD | PROFESSIONAL CLINICAL MENTAL HEALTH COUNSELOR | OTHER | 609550005 | 05 | MD |   | MEDICAID |