Provider Demographics
NPI:1366099244
Name:JACOBS, EMILY (LMT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACOBS
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 1:7040 CARROLL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4465
Mailing Address - Country:US
Mailing Address - Phone:202-643-9757
Mailing Address - Fax:
Practice Address - Street 1:7040 CARROLL AVE STE 3
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-4465
Practice Address - Country:US
Practice Address - Phone:202-643-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05197225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist