Provider Demographics
NPI:1194170951
Name:BORELLI, JESSICA LYNNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:BORELLI
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 1:721 VICKSBURG AVE
Mailing Address - Street 2:APT F
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2244
Mailing Address - Country:US
Mailing Address - Phone:405-426-5597
Mailing Address - Fax:
Practice Address - Street 1:301 W INTERSTATE 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-7701
Practice Address - Country:US
Practice Address - Phone:405-604-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT08360240171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator