Provider Demographics
NPI:1942826748
Name:BORUM, JEQUETTA
Entity Type:Individual
Prefix:
First Name:JEQUETTA
Middle Name:
Last Name:BORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JEQUETTA
Other - Middle Name:
Other - Last Name:BORUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ADT
Mailing Address - Street 1:4908 OAKLAND PARK RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4504
Mailing Address - Country:US
Mailing Address - Phone:443-909-2034
Mailing Address - Fax:
Practice Address - Street 1:4908 OAKLAND PARK RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4504
Practice Address - Country:US
Practice Address - Phone:443-909-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)