Provider Demographics
NPI:1922709658
Name:DEJOHNETTE, CRYSTOL MARIE
Entity Type:Individual
Prefix:
First Name:CRYSTOL
Middle Name:MARIE
Last Name:DEJOHNETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 S AUSTIN BLVD APT 3J
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2332
Mailing Address - Country:US
Mailing Address - Phone:773-759-8190
Mailing Address - Fax:
Practice Address - Street 1:1550 S INDIANA AVE STE 2NE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2857
Practice Address - Country:US
Practice Address - Phone:773-377-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108142104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker