Healthcare Provider Details

I. General information

NPI: 1164335378
Provider Name (Legal Business Name): JOHANNA JACOBSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 THAYER AVE STE 105
SILVER SPRING MD
20910-5734
US

IV. Provider business mailing address

8710 CAMERON ST UNIT 1407
SILVER SPRING MD
20910-3769
US

V. Phone/Fax

Practice location:
  • Phone: 240-641-4116
  • Fax:
Mailing address:
  • Phone: 615-289-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM07087
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: