Provider Demographics
NPI:1124390786
Name:LILLY, JERRY DUANE (EDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DUANE
Last Name:LILLY
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12073 N HUMPHREYS WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9343
Mailing Address - Country:US
Mailing Address - Phone:208-315-4855
Mailing Address - Fax:
Practice Address - Street 1:172 S ACADEMY AVE STE 160
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6564
Practice Address - Country:US
Practice Address - Phone:208-315-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6990101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional