Healthcare Provider Details

I. General information

NPI: 1780835579
Provider Name (Legal Business Name): JON FERGUSON MS, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N. MERIDIAN ST
INDIANAPOLIS IN
46204
US

IV. Provider business mailing address

6221 BROADWAY STREET
INDIANAPOLIS IN
46220
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-2704
  • Fax:
Mailing address:
  • Phone: 773-562-5023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166000644
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number99034514A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: