Provider Demographics
NPI:1710311980
Name:BRICENO, JORGE ALEJANDRO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ALEJANDRO
Last Name:BRICENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711492
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92171-1492
Mailing Address - Country:US
Mailing Address - Phone:858-432-3245
Mailing Address - Fax:
Practice Address - Street 1:1341 N ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2507
Practice Address - Country:US
Practice Address - Phone:858-432-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT104716106H00000X
CAIMF 73711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist