Basic Information
| Provider Information | |||||||||
| NPI: | 1194170951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORELLI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 VICKSBURG AVE | ||||||||
| Address2: | APT F | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730712244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054265597 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 W INTERSTATE 240 SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731397701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056049644 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2016 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | T08360240 | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.