Provider Demographics
NPI:1588306047
Name:RUNQUIST, JESSIKA ELIZABETH (MS)
Entity type:Individual
Prefix:
First Name:JESSIKA
Middle Name:ELIZABETH
Last Name:RUNQUIST
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 MALLARD POND CIR
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:GA
Mailing Address - Zip Code:30510-3039
Mailing Address - Country:US
Mailing Address - Phone:309-333-6759
Mailing Address - Fax:
Practice Address - Street 1:3116 DEMOREST MOUNT AIRY HWY
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5303
Practice Address - Country:US
Practice Address - Phone:706-778-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003359235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist