Provider Demographics
NPI:1811293095
Name:DERGANCE, JESSICA MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:DERGANCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 CHARTRES ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-1107
Mailing Address - Country:US
Mailing Address - Phone:815-224-1610
Mailing Address - Fax:815-223-1634
Practice Address - Street 1:2428 CHARTRES ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1107
Practice Address - Country:US
Practice Address - Phone:815-780-8765
Practice Address - Fax:815-780-8766
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490142771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical