Healthcare Provider Details

I. General information

NPI: 1700928876
Provider Name (Legal Business Name): LIFE BRIDGES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 OLD CHATTANOOGA PK.
CLEVELAND TN
37311
US

IV. Provider business mailing address

PO BOX 29
CLEVELAND TN
37364-0029
US

V. Phone/Fax

Practice location:
  • Phone: 423-472-5268
  • Fax: 423-479-1492
Mailing address:
  • Phone: 423-472-5268
  • Fax: 423-479-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC0000000617
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number20193
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2755
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1509
License Number StateTN
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANA JACKSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 423-472-5268