Provider Demographics
NPI:1891568630
Name:RUNYAN, JESSICA LEIGH (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MOUNTAIN COVE RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-2056
Mailing Address - Country:US
Mailing Address - Phone:423-402-1604
Mailing Address - Fax:
Practice Address - Street 1:7053 LEE HWY STE 301
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1823
Practice Address - Country:US
Practice Address - Phone:423-402-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11753225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist