=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093772733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTONIA JENSEN & ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1115-1 N SHOOP AVE
-----------------------------------------------------
City | WAUSEON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43567-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-335-6122
-----------------------------------------------------
Fax | 419-318-4157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 146
-----------------------------------------------------
City | WAUSEON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43567-0146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-335-6122
-----------------------------------------------------
Fax | 419-318-4157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANTONIA GRACIA GRIMOLIZZI-JENSEN
-----------------------------------------------------
Credential | LISW-S, ACSW, MSSA
-----------------------------------------------------
Telephone | 419-335-6122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | I-7226
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | I-7226
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | I-7226
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I-7226
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------