Provider Demographics
NPI:1184157000
Name:RUNKLE, JESSICA MAE (MS)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MAE
Last Name:RUNKLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MAE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:316 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21636-1126
Mailing Address - Country:US
Mailing Address - Phone:410-634-2380
Mailing Address - Fax:833-908-2287
Practice Address - Street 1:316 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:MD
Practice Address - Zip Code:21636-1126
Practice Address - Country:US
Practice Address - Phone:410-634-2380
Practice Address - Fax:833-908-2287
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC10729101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC10729OtherPROFESSIONAL CLINICAL MENTAL HEALTH COUNSELOR
MD609550002Medicaid
MD609550005Medicaid