Provider Demographics
NPI:1477903169
Name:BOYD, JONATHAN (MS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BOYD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 S WESTLAND AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2059
Mailing Address - Country:US
Mailing Address - Phone:407-415-2560
Mailing Address - Fax:
Practice Address - Street 1:4422 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3233
Practice Address - Country:US
Practice Address - Phone:813-384-4203
Practice Address - Fax:813-984-6729
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060650200Medicaid