Provider Demographics
NPI:1407560204
Name:BRISENO, JESSENIA
Entity Type:Individual
Prefix:
First Name:JESSENIA
Middle Name:
Last Name:BRISENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 S SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3144
Mailing Address - Country:US
Mailing Address - Phone:773-320-7381
Mailing Address - Fax:
Practice Address - Street 1:4058 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4639
Practice Address - Country:US
Practice Address - Phone:773-584-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105615104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker