Basic Information
| Provider Information | |||||||||
| NPI: | 1629042080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYDSTON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOYDSTON | ||||||||
| OtherFirstName: | J. | ||||||||
| OtherMiddleName: | CRAIG | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.C.S.W. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 137 HOSPITAL DR NE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337528 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 HOSPITAL DR NE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 1874 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 761910300 | 05 | FL | MEDICAID |