Healthcare Provider Details

I. General information

NPI: 1083884019
Provider Name (Legal Business Name): BRIDGING THE TYS TO JORDAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 S INDIANA AVE BSMT
CHICAGO IL
60637-1011
US

IV. Provider business mailing address

5500 S INDIANA AVE BSMT
CHICAGO IL
60637-1011
US

V. Phone/Fax

Practice location:
  • Phone: 773-425-8159
  • Fax: 773-488-9462
Mailing address:
  • Phone: 773-425-8159
  • Fax: 773-488-9462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberA-3249-0001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TYSON EVERETT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-425-8159