Healthcare Provider Details

I. General information

NPI: 1619576550
Provider Name (Legal Business Name): JENNIFER BRISENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 LONG BEACH BLVD
LONG BEACH CA
90807-3340
US

IV. Provider business mailing address

12108 HAYFORD ST
NORWALK CA
90650-6612
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 562-569-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: