Provider Demographics
NPI:1487124632
Name:BORRELLI, JAZETTE SHARICE
Entity type:Individual
Prefix:
First Name:JAZETTE
Middle Name:SHARICE
Last Name:BORRELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAZETTE
Other - Middle Name:SHARICE
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4130 LOUISIANA ST APT 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6727
Mailing Address - Country:US
Mailing Address - Phone:803-270-2213
Mailing Address - Fax:
Practice Address - Street 1:6216 OLD KEENE MILL CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2323
Practice Address - Country:US
Practice Address - Phone:803-270-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001266103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst