Provider Demographics
NPI:1104930973
Name:RUNYON, JEANNETTE H (SLP)
Entity type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:H
Last Name:RUNYON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SW LOBLOLLY PL
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-4242
Mailing Address - Country:US
Mailing Address - Phone:386-752-5534
Mailing Address - Fax:
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1455235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist