Provider Demographics
NPI:1821416967
Name:FADER, JON (MSW)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FADER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5334 PELHAM WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2214
Mailing Address - Country:US
Mailing Address - Phone:317-572-8204
Mailing Address - Fax:317-522-4367
Practice Address - Street 1:5334 PELHAM WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2214
Practice Address - Country:US
Practice Address - Phone:317-572-8204
Practice Address - Fax:317-522-4367
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN87000979A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health