Male or Other

Jerry D. Lilly ED.S

Full Name

Jerry Duane Lilly ED.S

NPI Number

1124390786

NPI Type

Individual Provider

Gender

Male

Enumeration Date

01/29/2012

Specialties

(Taxonomies)

Code

101YP2500X

Primary Taxonomy

No

Licenses

State

Idaho

License Number

LCPC-6990

Contact
Information

Purpose

Mailing
Location

Address

12073 N HUMPHREYS WAY
172 S ACADEMY AVE STE 160

City

Boise
Eagle

State

ID
ID

Postal Code

83714-9343
83616-6564

Country

US
US

Telephone Number

(208) 315-4855
(208) 315-4855

Provider data last refreshed from NPPES NPI registry on 11/19/2024

Data last updated by provider on 12/06/2023

Provider Address