=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437004249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKIE'S MYOMASSOLOGY HEALING AND WELLNESS LMT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2026
-----------------------------------------------------
Last Update Date | 02/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 831 N PONTIAC TRL LOT 70
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-633-4974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 831 N PONTIAC TRL LOT 70
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-633-4974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | JACKLYN JOAN-MARIE HANSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-633-4974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------