Provider Demographics
NPI:1053677856
Name:RUNYAN, JACQUELINE BAYS
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BAYS
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:BAYS
Other - Last Name:RUNYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, NCC, NCSC
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8708
Mailing Address - Country:US
Mailing Address - Phone:770-962-5100
Mailing Address - Fax:770-962-7006
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8708
Practice Address - Country:US
Practice Address - Phone:770-962-5100
Practice Address - Fax:770-962-7006
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0555526101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional