Healthcare Provider Details

I. General information

NPI: 1053768135
Provider Name (Legal Business Name): JESSICA L LIU-KEBAILI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 10/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 WEEPING WILLOW CT APT 42
ASPEN HILL MD
20906-2567
US

IV. Provider business mailing address

13 JERMAE STREET
THURMONT MD
21788
US

V. Phone/Fax

Practice location:
  • Phone: 240-440-1094
  • Fax:
Mailing address:
  • Phone: 240-440-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberR01808
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019014538
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT2020
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: