Provider Demographics
NPI:1528444999
Name:JRL BROKEN ARROW LLC
Entity type:Organization
Organization Name:JRL BROKEN ARROW LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-216-4800
Mailing Address - Street 1:6280 W 9600 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9234
Mailing Address - Country:US
Mailing Address - Phone:801-216-4800
Mailing Address - Fax:
Practice Address - Street 1:2610 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2714
Practice Address - Country:US
Practice Address - Phone:801-216-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTISSUED BY NAME324500000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility