Provider Demographics
NPI:1881109544
Name:JORDAN RULLO LLC
Entity type:Organization
Organization Name:JORDAN RULLO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:RULLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-991-3042
Mailing Address - Street 1:2958 S METROPOLITAN WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2237
Mailing Address - Country:US
Mailing Address - Phone:385-202-4250
Mailing Address - Fax:
Practice Address - Street 1:1433 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2434
Practice Address - Country:US
Practice Address - Phone:385-202-4250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health