Healthcare Provider Details

I. General information

NPI: 1467387589
Provider Name (Legal Business Name): IGNITE UNION COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 S PROVIDENCE RD STE B
WAXHAW NC
28173-8350
US

IV. Provider business mailing address

2036 HAMIL RIDGE DR
WAXHAW NC
28173-6023
US

V. Phone/Fax

Practice location:
  • Phone: 704-256-1401
  • Fax:
Mailing address:
  • Phone: 917-445-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER JENNIFER
Title or Position: PART OWNER
Credential: MS, OTR/L
Phone: 917-445-0988