Healthcare Provider Details

I. General information

NPI: 1194170951
Provider Name (Legal Business Name): JESSICA LYNNE BORELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SE 4TH ST STE A
MOORE OK
73160-7328
US

IV. Provider business mailing address

3721 BURMA CT
NORMAN OK
73072-5043
US

V. Phone/Fax

Practice location:
  • Phone: 405-837-1033
  • Fax:
Mailing address:
  • Phone: 405-426-5597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT08360240
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: