Healthcare Provider Details

I. General information

NPI: 1033981089
Provider Name (Legal Business Name): JAKE CLIFTON KELOW III LSW/CADC/ATE/COPD I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 MADISON ST
MAYWOOD IL
60153-2136
US

IV. Provider business mailing address

411 MADISON ST
MAYWOOD IL
60153-2136
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-3500
  • Fax:
Mailing address:
  • Phone: 708-450-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149031643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: