Healthcare Provider Details

I. General information

NPI: 1487881546
Provider Name (Legal Business Name): JASON KENNETH LEUBNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST 605
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

1300 N 12TH ST 605
PHOENIX AZ
85006-2848
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-4567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number45424
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: