Provider Demographics
NPI:1205193109
Name:LEATHEM, JARRETT MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JARRETT
Middle Name:MICHAEL
Last Name:LEATHEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 W GREENWAY RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4226
Mailing Address - Country:US
Mailing Address - Phone:480-573-0130
Mailing Address - Fax:480-573-0131
Practice Address - Street 1:2525 W GREENWAY RD STE 125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4226
Practice Address - Country:US
Practice Address - Phone:480-573-0130
Practice Address - Fax:480-573-0131
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ007328208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program