Provider Demographics
NPI:1578840351
Name:DESJARLAIS, VIRGINIA (PHD, LCPC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:DESJARLAIS
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 COLMAN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2747
Mailing Address - Country:US
Mailing Address - Phone:815-399-4300
Mailing Address - Fax:815-399-6303
Practice Address - Street 1:1243 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-6240
Practice Address - Country:US
Practice Address - Phone:815-520-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional