Healthcare Provider Details

I. General information

NPI: 1194302737
Provider Name (Legal Business Name): JONATHAN BORDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-5600
  • Fax:
Mailing address:
  • Phone: 617-724-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number1026637
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: