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General NPI Number Information
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NPI Number | 1811435027
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Entity Type | Individual
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Provider Name | JERMAINE ANTHONY SR. LCSW,CRADC, DOT-SAP
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Gender | Male
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Dates
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Enumeration Date | 02/08/2017
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 8892 LOUISANA STREET, SUITE D-2
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City | MERRILLVILLE
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State | IN
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Zip | 46410-4641
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Country | US
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Telephone | 630-677-0450
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Fax | 314-431-6420
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Provider Business Mailing Address
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Address Line | PO BOX 2964
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City | EAST CHICAGO
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State | IN
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Zip | 46312-7964
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Country | US
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Telephone | 630-677-0450
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Fax | 314-431-6420
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 31221
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.028647
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License Number State | IL
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