Provider Demographics
NPI:1083884019
Name:BRIDGING THE TYS TO JORDAN INC
Entity Type:Organization
Organization Name:BRIDGING THE TYS TO JORDAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-425-8159
Mailing Address - Street 1:7122 S VINCENNES AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-2661
Mailing Address - Country:US
Mailing Address - Phone:773-425-8159
Mailing Address - Fax:
Practice Address - Street 1:7122 S VINCENNES AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2661
Practice Address - Country:US
Practice Address - Phone:773-425-8159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-3249-0001251B00000X
251S00000X, 261QR0401X, 276400000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility