MEDICARE: JESSENIA 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
1	104100000X	Social Worker	150.105615	IL

General Provider Information

NPI Number	:	1407560204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSENIA BRISENO

Provider Business Mailing Address
First Line	:	2304 S SAINT LOUIS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3144
Country	:	US
Telephone Number	:	773-320-7381
Fax Number	:

Provider Business Practice Location Address
First Line	:	4058 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4639
Country	:	US
Telephone Number	:	773-584-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2023
Last Update Date	:	02/08/2023

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Directions to “ JESSENIA BRISENO ” Practice Location

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