Provider Demographics
NPI:1144521501
Name:BLACK, JONATHAN R (PSYD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7546 OAKBORO DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7504
Mailing Address - Country:US
Mailing Address - Phone:954-629-8150
Mailing Address - Fax:
Practice Address - Street 1:2290 NW 2ND AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7457
Practice Address - Country:US
Practice Address - Phone:561-706-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8145103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical