Provider Demographics
NPI:1093710303
Name:TYKES & TEENS, INC.
Entity Type:Organization
Organization Name:TYKES & TEENS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRANT AND CONTRACT MANGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JEASONNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-210-0156
Mailing Address - Street 1:900 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2471
Mailing Address - Country:US
Mailing Address - Phone:772-220-3439
Mailing Address - Fax:772-220-3484
Practice Address - Street 1:900 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3502
Practice Address - Country:US
Practice Address - Phone:772-220-3439
Practice Address - Fax:772-220-3484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-43-AD-0899-00101YA0400X
101YM0800X, 1041C0700X, 251B00000X, 251S00000X, 363LP0200X
FLARNP9469081363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL360230300Medicaid