Provider Demographics
NPI:1548316714
Name:BERENSON, JESSICA (LISW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BERENSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3004
Mailing Address - Country:US
Mailing Address - Phone:505-872-8353
Mailing Address - Fax:505-888-5473
Practice Address - Street 1:2724 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3004
Practice Address - Country:US
Practice Address - Phone:505-872-8353
Practice Address - Fax:505-888-5473
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-047871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical