Provider Demographics
NPI:1003992181
Name:BOLTON, JONINA DAUM (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONINA
Middle Name:DAUM
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 N UNIVERSITY DR
Mailing Address - Street 2:SUITE C-100
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6249
Mailing Address - Country:US
Mailing Address - Phone:954-742-7449
Mailing Address - Fax:954-742-7169
Practice Address - Street 1:4300 N UNIVERSITY DR
Practice Address - Street 2:SUITE C-100
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6249
Practice Address - Country:US
Practice Address - Phone:954-742-7449
Practice Address - Fax:954-742-7169
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical