Provider Demographics
NPI:1689392177
Name:LEGACY THERAPEUTIC INTERVENTIONS, PLLC
Entity Type:Organization
Organization Name:LEGACY THERAPEUTIC INTERVENTIONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:YAZLYN
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-674-9965
Mailing Address - Street 1:5403 NESSEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-4600
Mailing Address - Country:US
Mailing Address - Phone:678-674-9965
Mailing Address - Fax:
Practice Address - Street 1:5403 NESSEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-4600
Practice Address - Country:US
Practice Address - Phone:678-674-9965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty