Healthcare Provider Details

I. General information

NPI: 1659224947
Provider Name (Legal Business Name): JT LEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5927 SUNRISE CT
CHARLOTTE NC
28212-5762
US

IV. Provider business mailing address

5927 SUNRISE CT
CHARLOTTE NC
28212-5762
US

V. Phone/Fax

Practice location:
  • Phone: 919-685-6274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TENBITE SEYOUM
Title or Position: FOUNDER
Credential:
Phone: 919-685-6274