Provider Demographics
NPI:1760192975
Name:JENSEN, MIA FIORE ROSENTHAL (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:FIORE ROSENTHAL
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:FIORE
Other - Last Name:ROSENTHAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:214 E SCRANTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2532
Mailing Address - Country:US
Mailing Address - Phone:847-477-7346
Mailing Address - Fax:
Practice Address - Street 1:115 S MARION ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2826
Practice Address - Country:US
Practice Address - Phone:847-477-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013961101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty