MEDICARE: JORDAN RULLO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center		UT

General Provider Information

NPI Number	:	1881109544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN RULLO LLC

Provider Business Mailing Address
First Line	:	2958 S METROPOLITAN WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2237
Country	:	US
Telephone Number	:	385-202-4250
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2434
Country	:	US
Telephone Number	:	385-202-4250
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST/MANAGER
Name	:	DR. JORDAN ELIZABETH RULLO
Credential	:	PHD
Telephone Number	:	612-991-3042

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	12/04/2017

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