Healthcare Provider Details

I. General information

NPI: 1659017499
Provider Name (Legal Business Name): LEADING EDGE HEALTHCARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 N MONTEZUMA ST STE A
PRESCOTT AZ
86301-2066
US

IV. Provider business mailing address

2182 MARK AVE
PRESCOTT AZ
86301-1029
US

V. Phone/Fax

Practice location:
  • Phone: 928-925-2871
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JACOB KIRKEENG
Title or Position: OWNER MEMBER
Credential: PA-C
Phone: 928-925-2871