Healthcare Provider Details

I. General information

NPI: 1275415697
Provider Name (Legal Business Name): JONATHAN ESCOBEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 WHIPPLE ST
PRESCOTT AZ
86301-1705
US

IV. Provider business mailing address

919 PROSSER LN
PRESCOTT AZ
86301-1756
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-5211
  • Fax:
Mailing address:
  • Phone: 602-349-6337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-21951
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: