Provider Demographics
NPI:1093772733
Name:ANTONIA JENSEN & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ANTONIA JENSEN & ASSOCIATES, LLC
Other - Org Name:AJA BEHAVIORAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTONIA
Authorized Official - Middle Name:GRACIA
Authorized Official - Last Name:GRIMOLIZZI-JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S, ACSW, MSSA
Authorized Official - Phone:419-335-6122
Mailing Address - Street 1:P.O. BOX 146
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0146
Mailing Address - Country:US
Mailing Address - Phone:419-335-6122
Mailing Address - Fax:419-318-4157
Practice Address - Street 1:1115-1 N SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1857
Practice Address - Country:US
Practice Address - Phone:419-335-6122
Practice Address - Fax:419-318-4157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-7226101YA0400X, 101YM0800X, 101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH282524354005OtherMEDICAL MUTUAL
OH000000371817OtherANTHEM BC & BS
OH716572000OtherMAGELLAN HEALTH SERVICES
OHAN9345711Medicare PIN