Provider Demographics
NPI:1225792427
Name:ANTWINE-JELANI, DAMO (NCSP)
Entity type:Individual
Prefix:
First Name:DAMO
Middle Name:
Last Name:ANTWINE-JELANI
Suffix:
Gender:
Credentials:NCSP
Other - Prefix:
Other - First Name:DAMIEN
Other - Middle Name:
Other - Last Name:ANTWINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NCSP
Mailing Address - Street 1:429 N WEBER RD STE B-274
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-3902
Mailing Address - Country:US
Mailing Address - Phone:630-864-0704
Mailing Address - Fax:
Practice Address - Street 1:2650 W 35TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1416
Practice Address - Country:US
Practice Address - Phone:630-864-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10307188103TS0200X
IL1185755103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ63445Medicaid
IL1185755Medicaid
IL6099042Medicaid