Provider Demographics
NPI:1487308102
Name:CRUNKLETON, JESSICA M
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:CRUNKLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 BELLEVILLE CROSSING ST # 1015
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-3108
Mailing Address - Country:US
Mailing Address - Phone:219-386-6645
Mailing Address - Fax:
Practice Address - Street 1:2427 PRO TOUR DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4853
Practice Address - Country:US
Practice Address - Phone:219-386-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021028230101YM0800X
IN35002024A101YM0800X
IN39003344A101YM0800X
MO2021028229101YM0800X
IL180.014386101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty