Provider Demographics
NPI:1629042080
Name:BOYDSTON, JONATHAN CRAIG (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:CRAIG
Last Name:BOYDSTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:J.
Other - Middle Name:CRAIG
Other - Last Name:BOYDSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:13936 GROVER RD.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5063
Mailing Address - Country:US
Mailing Address - Phone:850-855-8601
Mailing Address - Fax:
Practice Address - Street 1:13936 GROVER RD.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5063
Practice Address - Country:US
Practice Address - Phone:850-855-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLSW 18741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761910300Medicaid
FL761910300Medicaid