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NPI Code Detail

MEDICARE: JONATHAN SAMUEL BRISENO

MEDICARE: JONATHAN SAMUEL BRISENO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical PsychologistPSY10001791MA
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1326661893
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN SAMUEL BRISENO
Provider Business Mailing Address
First Line : 76 SUMNER ST
Second Line :
City : BOSTON
State : MA
Zip : 02128-2319
Country : US
Telephone Number : 956-775-4106
Fax Number :
Provider Business Practice Location Address
First Line : 151 EVERETT AVE
Second Line :
City : CHELSEA
State : MA
Zip : 02150-1807
Country : US
Telephone Number : 617-889-8515
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/19/2020
Last Update Date : 03/13/2026

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Directions to “ JONATHAN SAMUEL BRISENO ” Practice Location

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